EX-99.B5A 3 gacdf-1109app.txt DEFERRED APPLICATION Annuities ING GoldenSelect Deferred Variable Annuity Customer Data Form for the States of: Alabama Missouri Alaska Nebraska Arizona Nevada Arkansas New Jersey California New Mexico Colorado Ohio Delaware Oklahoma District of Columbia Oregon Florida Pennsylvania Georgia Rhode Island Hawaii South Carolina Idaho South Dakota Indiana Tennessee Iowa Texas Kansas Utah Kentucky Vermont Louisiana Virginia Maine Washington Michigan West Virginia Minnesota Wisconsin Mississippi Wyoming ING GOLDENSELECT(r) ANNUITIES ING (Lion Logo) Issued by Golden American Life Insurance Company Distributed by Directed Services, Inc., member NASD. GOOD ORDER CHECKLIST -------------------------------------------------------------------------------- PAGE 1 _ The Name, Trust Date (if applicable), Address, Date of Birth, Social Security Number/Tax Identification Number is provided for each individual/entity named. PAGE 2 _ The Primary or Contingent status for each named Beneficiary is entered in section 3. _ Each Beneficiary is named individually. If there are any trust designations, the trust name and the trust date is included. _ Designated Beneficiary percentages are clearly entered and total 100% for all Primary Beneficiaries and 100% for all Contingent Beneficiaries. _ If a separate sheet containing additional Beneficiary information is needed, that sheet must be signed and dated by the owner. PAGE 3 _ If a transfer is required, the approximate transfer amount is entered in section 4. If there are multiple transfers, each approximate transfer amount is entered separately. _ The initial premium meets the selected product's minimum requirements. _ Select one product, death benefit and optional living benefit rider. _ Enhanced Death Benefits or Earnings Multiplier cannot be selected with Joint Owners. _ If Telephone Reallocation Authorization is selected, the owner has initialed where requested to authorize the agent. The name and social security number for each additional person is entered in section 6. PAGE 4 _ The tax type for new annuity (ie: Non-Qualified, IRA, Simple IRA, TSA) is indicated in section 7, and any applicable conversion/establishment dates provided. _ If a replacement is involved, the appropriate transfer and state replacement forms are completed and submitted with this form. PAGE 5 _ All allocations (fixed and variable) total 100% of the initial investment amount. Do not complete this section if an Optional Asset Allocation Model Portfolio is selected. PAGE 6 _ If DCA is desired, the DCA target fund allocations total 100%. Source Funds total 100%. PAGE 7 _ One Optional Asset Allocation Model Portfolio is chosen. The selection is clearly marked in section 11. 100% of the initial investment amount will be allocated into the one model portfolio chosen. Sections 9 and 10 should not be completed if an asset allocation model is used. PAGE 8 _ For any of the optional automatic programs, all of the information requested is submitted with this form. PAGE 9 _ The owner has signed and dated section 14, including the City and State where this customer data form was signed. If this is different from the owners resident state, an explanation is provided at the top of page 1. _ If this form is signed by a Power of Attorney, Legal Guardian, etc, a copy of the appropriate supporting documentation is provided confirming the signer's ability to act on behalf of the owner. PAGE 10 _ The name, social security number, phone number, broker/dealer branch, and signature for each agent is provided. _ If more than one agent is listed, the agent commission split is entered and totals 100%. ________________________________________________________________________________ CUSTOMER SERVICE CENTER MAILING INSTRUCTIONS: Send all completed and signed documents to : For Regular Mail: ING ANNUITIES For Overnight Delivery:ING ANNUITIES Attn: New Business Attn: New Business P.O. Box 9271 909 Locust Street Des Moines, IA 50306-9271 Des Moines, IA 50309-2899 To contact our Licensing Department please call: 800-235-5695 To contact our Client Services Department please call: 800-366-0066 To contact our Sales Desk please call: INDEPENDENT DIVISION NYSE/REGIONAL DIVISION 800-344-6860 800-243-3706 ________________________________________________________________________________ ING (Lion Logo) GOLDEN AMERICAN LIFE INSURANCE COMPANY PO Box 9271 Des Moines, IA 50306-9271 Phone: (800) 366-0066 Overnight Delivery: ING Annuities 909 Locust Street Des Moines, IA 50309-2899 ING GOLDENSELECT DEFERRED VARIABLE ANNUITY CUSTOMER DATA FORM ________________________________________________________________________________ FOR AGENT USE ONLY: Client's Account Number:____________________________________ If this customer data form is being signed in a state other than the owner's resident state, please specify the state where the business was solicited and the purpose of the visit._______________________________________________________ ________________________________________________________________________________ 1(A) OWNER (Please provide supporting documentation for all non-natural owners) Name:_____________________________________________ Trust Date:__________________ SSN or Tax ID:___________________________ DOB:__________________ _ Male _ Female Permanent Street Address:_______________________________________________________ City:______________________________________ State:_________________ Zip:________ Phone:_____________________________________ EMail Address:______________________ ________________________________________________________________________________ 1(B) JOINT OWNER (Standard Death Benefit only option; Earnings Multiplier not available) Relationship to Owner:__________________________________________________________ Name:_____________________________________________ Trust Date:__________________ SSN or Tax ID:___________________________ DOB:__________________ _ Male _ Female Permanent Street Address:_______________________________________________________ City:______________________________________ State:_________________ Zip:________ Phone:_____________________________________ EMail Address:______________________ ________________________________________________________________________________ 2(A) ANNUITANT (If other than owner) Name:___________________________________________________________________________ SSN or Tax ID:___________________________ DOB:__________________ _ Male _ Female Permanent Street Address:_______________________________________________________ City:______________________________________ State:_________________ Zip:________ Phone:_____________________________________ EMail Address:______________________ (A) ________________________________________________________________________________ 2(B) CONTINGENT ANNUITANT (Optional) Name:___________________________________________________________________________ SSN or Tax ID:___________________________ DOB:__________________ _ Male _ Female Permanent Street Address:_______________________________________________________ City:______________________________________ State:_________________ Zip:________ Phone:_____________________________________ EMail Address:______________________ ________________________________________________________________________________ GA-CDF-1109 Page 1 of 10 126030 11/01/2003 ________________________________________________________________________________ 3 BENEFICIARY(S) Must be Completed RESTRICTED BENEFICIARY. If selected, complete a "Restricted Beneficiary" form and submit with this form. ________________________________________________________________________________ _ PRIMARY BENEFICIARY Name:_____________________________________ Date of Birth____________ Percent____ SSN or Tax ID:____________________________ Relationship to Owner________________ Address:________________________________________________________________________ ________________________________________________________________________________ _ PRIMARY _ CONTINGENT BENEFICIARY 2 Name:_____________________________________ Date of Birth____________ Percent____ SSN or Tax ID:____________________________ Relationship to Owner________________ Address:________________________________________________________________________ ________________________________________________________________________________ _ PRIMARY _ CONTINGENT BENEFICIARY 3 Name:_____________________________________ Date of Birth____________ Percent____ SSN or Tax ID:____________________________ Relationship to Owner________________ Address:________________________________________________________________________ ________________________________________________________________________________ _ PRIMARY _ CONTINGENT BENEFICIARY 4 Name:_____________________________________ Date of Birth____________ Percent____ SSN or Tax ID:____________________________ Relationship to Owner________________ Address:________________________________________________________________________ *For additional Beneficiary designations, attach a separate page, signed and dated by the owner(s). *Beneficiaries will be split equally if no percentages are provided. ________________________________________________________________________________ SAMPLE BENEFICIARY DESIGNATIONS Be sure to use given names such as "Mary M. Doe", not "Mrs. John Doe", and include the address and relationship of the beneficiary or beneficiaries to the owner. The following designations may be helpful to you: | | Name Relationship to Owner Percent -------------------------------------------------------------------------------- One Primary | Beneficiary | Mary M. Doe Sister 100% -------------------|------------------------------------------------------------ Two Primary | Beneficiaries | Jane J. Doe Mother 50% | John J. Doe Father 50% -------------------|------------------------------------------------------------ One Primary | Beneficiary | Jane J. Doe Wife 100% One Contingent | John J. Doe Son 100% -------------------|------------------------------------------------------------ Estate | Estate of John Doe -------------------|------------------------------------------------------------ Trust | ABC Trust Trust Name, | dtd 1/1/85 dtd (Date of Trust | Agreement) -------------------|------------------------------------------------------------ Testamentary Trust | Trust created by Testamentary Trust | the (Trust established | Last Will and Testament | within the owners will) | of John Doe -------------------------------------------------------------------------------- ________________________________________________________________________________ GA-CDF-1109 Page 2 of 10 126030 11/01/2003 ________________________________________________________________________________ 4 INITIAL INVESTMENT Initial Investment (Please make any checks payable to Golden American Life Insurance Company) _ Initial Premium Paid $________________________________________________________ _ Estimated amount of Transfer/1035 Exchange $__________________________________ ________________________________________________________________________________ 5 PRODUCT SELECTION Product (Must Select One) _ Premium Plus _ ES II _ Landmark _ Access(Not available in the state of OR) -------------------------------------------------------------------------------- Death Benefit Option (Select One. If a death benefit is not chosen, the death benefit will be the Standard Death Benefit.) _ Standard (This is the only benefit option available to Joint Owners) _ Quarterly Ratchet _ MAX 7(In the state of WA this benefit is named MAX 5.5) -------------------------------------------------------------------------------- Optional Earnings Multiplier _ (Not available for Joint Owners or in the state of WA) -------------------------------------------------------------------------------- Optional Living Benefit (May Select One) _ Minimum Guaranteed Accumulation Benefit 10YR (MGAB10) (Not available in the state of OR) _ Minimum Guaranteed Income Benefit (MGIB) (Not available in the states of MN and OR) _ Minimum Guaranteed Withdrawal Benefit(MGWB) (Not available in the state of OR) (not available with Premium Plus) ________________________________________________________________________________ 6 TELEPHONE REALLOCATION AUTHORIZATION I authorize Golden American Life Insurance Company (the Company) to act upon reallocation instructions, given by electronic means or voice command from the agent that signs in section 15 and/or the following individuals listed below upon furnishing their social security number or alternative identification number. To authorize the agent, owner must initial: _____________________ Provide the name and social security number of other authorized individuals below: Name_____________________________ Social Security Number________________________ Name_____________________________ Social Security Number________________________ Neither the Company nor any person authorized by the Company will be responsible for any claim, loss, liability, or expense in connection with reallocation instructions received by electronic means or voice command from such person if the Company or other such person acted on such electronic means or voice command in good faith in reliance upon this authorization. The Company will continue to act upon this authorization until such time as the person indicated above is no longer affiliated with the broker/dealer under which my contract was purchased or until such time as I notify the Company in writing of a change in instructions. Note: If the authorized person's social security number is not provided, the individual will not be authorized. ________________________________________________________________________________ GA-CDF-1109 Page 3 of 10 126030 11/01/2003 ________________________________________________________________________________ 7 PLAN TYPE _ Non-Qualified _ 1035 Exchange ________________________________________________________________________________ _ IRA _ IRA Transfer _ IRA Rollover from Qualified Plan _ SEP-IRA _ 403(b) _ 457 Plan _ Qualified Other_________ Indicate contribution amount and appropriate tax year___________________________ _ Roth IRA If transfer, provide original conversion/establishment date and amount__________ _ Simple IRA If transfer, provide original establishment date and amount_____________________ ________________________________________________________________________________ 8 IMPORTANT NOTICE REGARDING REPLACEMENT Do you currently have any existing annuity or life insurance policies or coverage? _ Yes (Please continue below) _ No This purchase may involve discontinuing or changing an existing policy or contract. If so, a replacement is occurring. Financed purchases are also considered replacements. A replacement occurs when a new policy or contract is purchased and in connection with the sale you discontinue making premium payments on the existing policy or contract or an existing policy or contract is surrendered, forfeited, assigned to the replacing insurer or otherwise terminated or used in a financed purchase. A financed purchase occurs when the purchase of a new life insurance policy or an annuity contract involves the use of funds obtained by the withdrawal or surrender of or by borrowing some or all of the policy values including accumulated dividends of an existing policy to pay all or part of any premium or payment due on the new policy. A financed purchase is a replacement. You should carefully consider whether a replacement is in your best interest. You will pay acquisition costs and there may be surrender costs deducted from your policy or contract. You may be able to make changes to your existing policy or contract to meet your insurance needs at less cost. A financed purchase will reduce the value of your existing policy and may reduce the amount paid upon the death of the insured. We want you to understand the effects of replacements before you make your purchase decision and ask that you answer the following questions. 1. Are you considering discontinuing making premium payments, surrendering, forfeiting, assigning to the insurer, or otherwise terminating your existing policy or contract? _ Yes _ No 2. Are you considering using funds from your existing policies or contracts to pay premiums due on this new policy or contract? _ Yes _ No If you answered "Yes" to either of the above questions, please complete and return with this form a copy of any state replacement form(s), if applicable. I do not want this notice read aloud to me, _____________ (Owner/Applicants must initial here ONLY if they do not want the above notice read aloud.) ________________________________________________________________________________ GA-CDF-1109 Page 4 of 10 126030 11/01/2003 ________________________________________________________________________________ 9 INITIAL ALLOCATIONS Enter initial allocations in whole percentages. Do not complete this section if an Optional Asset Allocation Model Portfolio is chosen. Please see section 11 for Optional Asset Allocation Model Portfolio selection. VARIABLE ALLOCATIONS ____% A I M V.I. Dent Demographic Trends1 ____% ING MFS Total Return1 ____% Colonial Small Cap Value ____% ING PIMCO Core Bond1,2 ____% Fidelity VIP Equity-Income1 ____% ING Salomon Bros Aggr Growth1 ____% Fidelity VIP Growth1 ____% ING Salomon Bros All Cap1 ____% ING AIM Mid Cap Growth1 ____% ING Salomon Bros Investors1 ____% ING Alliance Mid Cap Growth1 ____% ING T.Rowe Price Capital App1 ____% ING American Funds Growth1 ____% ING T.Rowe Price Equity Income1 ____% ING American Funds Growth-Income1 ____% ING UBS US Balanced1 ____% ING American Funds International1 ____% ING VP Bond Portfolio1,2 ____% ING Cap Guardian Large Cap Value1 ____% ING VP Growth Opportunities1 ____% ING Cap Guardian Mangd Glbl1 ____% ING VP Index Plus LargeCap1 ____% ING Cap Guardian Small Cap1 ____% ING VP Magnacap1 ____% ING Developing World Portfolio1 ____% ING VP SmallCap Opp1 ____% ING Eagle Asset Value Equity1 ____% ING VP Worldwide Growth1 ____% ING FMR Diversified Mid Cap1 ____% ING VanKampen Equity Growth1 ____% ING Goldman Sachs Internet Toll1 ____% ING VanKampen Glbl Franchise1 ____% ING Hard Assets1 ____% ING VanKampen Gr and Income1 ____% ING International1 ____% ING VanKampen Real Estate1 ____% ING Janus Growth and Income1 ____% INVESCO VIF Fin Services ____% ING Janus Special Equity1 ____% INVESCO VIF Health Sciences ____% ING Jennison Equity Opportunities1 ____% INVESCO VIF Leisure ____% ING JPMorgan Int'l1 ____% INVESCO VIF Utilities ____% ING JPMorgan Small Cap Equity1 ____% Jennison Portfolio1 ____% ING Julius Baer Foreign1 ____% PIMCO High Yield Portfolio ____% ING Limited Maturity Bond1,2 ____% Pioneer Fund VCT Portfolio1 ____% ING Liquid Assets1,2 ____% Pioneer Mid-Cap Value VCT ____% ING Marsico Growth1 ____% ProFund VP Bull ____% ING Mercury Focus Value1 ____% ProFund VP Europe 30 ____% ING Mercury Fundamental Growth1 ____% ProFund VP Rising Rates Opp1,2 ____% ING MFS Mid Cap Growth1 ____% ProFund VP Small-Cap ____% ING MFS Research1 ____% SP Jennison Int'l Growth1 FIXED ALLOCATIONS Enter the allocation percentage and the fixed interest period. Check availability prior to selection. ____% 6 Month DCA ____% __________ Year Fixed ____% __________ Year Fixed ____% __________ Year Fixed ____% __________ Year Fixed ____% __________ Year Fixed 100% Initial Allocation Total Do the variable and fixed allocations total 100%? 1 The available share class is subject to distribution and/or service (12b-1) fees. 2 Transfers to and from and amounts invested in these portfolios may affect death benefit and living benefit guarantees. ________________________________________________________________________________ GA-CDF-1109 Page 5 of 10 126030 11/01/2003 ________________________________________________________________________________ 10 DOLLAR COST AVERAGING (DCA) OPTIONAL 1) DCA SOURCE FUNDS (From) - A minimum of $1,200 must be allocated into one of the following source funds. Enter the DCA source fund allocation in whole percentages below. ____% ING Limited Maturity Bond1,2 ____% ING Liquid Assets1,2 ____% 1 YR DCA ____% 6-Month DCA ________________________________________________________________________________ 2) DCA ALLOCATIONS (To) - Specify in whole percentages the Account Divisions for the DCA transfers. |____% A I M V.I. Dent Demographic Trends1 | ____% ING MFS Total Return1 |____% Colonial Small Cap Value | ____% ING PIMCO Core Bond1,2 |____% Fidelity VIP Equity-Income1 | ____% ING Salomon Bros Aggr Growth1 |____% Fidelity VIP Growth1 | ____% ING Salomon Bros All Cap1 |____% ING AIM Mid Cap Growth1 | ____% ING Salomon Bros Investors1 |____% ING Alliance Mid Cap Growth1 | ____% ING T.Rowe Price Capital App1 |____% ING American Funds Growth1 | ____% ING T.Rowe Price Equity Inc1 |____% ING American Funds Growth-Income1 | ____% ING UBS US Balanced1 |____% ING American Funds International1 | ____% ING VP Bond Portfolio1,2 |____% ING Cap Guardian Large Cap Value1 | ____% ING VP Growth Opportunities1 |____% ING Cap Guardian Mangd Glbl1 | ____% ING VP Index Plus LargeCap1 |____% ING Cap Guardian Small Cap1 | ____% ING VP Magnacap1 |____% ING Developing World Portfolio1 | ____% ING VP SmallCap Opp1 |____% ING Eagle Asset Value Equity1 | ____% ING VP Worldwide Growth1 |____% ING FMR Diversified Mid Cap1 | ____% ING VanKampen Equity Growth1 |____% ING Goldman Sachs Internet Toll1 | ____% ING VanKampen Glbl Franchise1 |____% ING Hard Assets1 | ____% ING VanKampen Gr and Income1 |____% ING International1 | ____% ING VanKampen Real Estate1 |____% ING Janus Growth and Income1 | ____% INVESCO VIF Fin Services |____% ING Janus Special Equity1 | ____% INVESCO VIF Health Sciences |____% ING Jennison Equity Opportunities1 | ____% INVESCO VIF Leisure |____% ING JPMorgan Int'l1 | ____% INVESCO VIF Utilities |____% ING JPMorgan Small Cap Equity1 | ____% Jennison Portfolio1 |____% ING Julius Baer Foreign1 | ____% PIMCO High Yield Portfolio |____% ING Limited Maturity Bond1,2 | ____% Pioneer Fund VCT Portfolio1 |____% ING Liquid Assets1,2 | ____% Pioneer Mid-Cap Value VCT |____% ING Marsico Growth1 | ____% ProFund VP Bull |____% ING Mercury Focus Value1 | ____% ProFund VP Europe 30 |____% ING Mercury Fundamental Growth1 | ____% ProFund VP Rising Rates Op1,2 |____% ING MFS Mid Cap Growth1 | ____% ProFund VP Small-Cap |____% ING MFS Research1 | ____% SP Jennison Int'l Growth1 ________________________________________________________________________________ 100% DCA Allocation Total Do the DCA allocations total 100%? ________________________________________________________________________________ 1 The available share class is subject to distribution and/or service (12b-1) fees. 2 Transfers to and from and amounts invested in these portfolios may affect death benefit and living benefit guarantees. ________________________________________________________________________________ GA-CDF-1109 Page 6 of 10 126030 11/01/2003 ________________________________________________________________________________ 11 OPTIONAL ASSET ALLOCATION MODEL PORTFOLIOS (Select One) Asset Allocation Model Portfolios are designed to help individuals choose investment options when purchasing a variable insurance product. The goal of the process is to maximize total investment return at a given level of risk by diversifying a contract owner's portfolio among different asset classes, namely stocks, bonds and money market instruments. For allocations other than the models shown below, please complete section 9 of this form. Select one asset allocation model portfolio below. 100% of your initial investment will be invested as described for the model you choose. PLEASE ALLOCATE 100% OF MY INITIAL INVESTMENT AMOUNT INTO THE FOLLOWING MODEL PORTFOLIO: (Select one below) ________________________________________________________________________________ _ PORTFOLIO 1 _ CONSERVATIVE Small/Mid Cap 5% Pioneer Mid-Cap Value VCT Portfolio1 Large Cap Growth 5% Fidelity VIP Growth Portfolio1 Large Cap Value 10% ING T. Rowe Price Equity Income Portfolio1 Bonds 45% ING PIMCO Core Bond Portfolio1,2 Stability of Principal 35% ING Liquid Assets Portfolio1,2 ________________________________________________________________________________ _ PORTFOLIO 2 _ MODERATELY CONSERVATIVE Global/International 5% SP Jennison International Growth Portfolio1 Small/Mid Cap 10% Pioneer Mid-Cap Value VCT Portfolio1 Large Cap Growth 10% Fidelity VIP Growth Portfolio1 Large Cap Value 15% ING T. Rowe Price Equity Income Portfolio1 Bonds 45% ING PIMCO Core Bond Portfolio1,2 Stability of Principal 15% ING Liquid Assets Portfolio1,2 ________________________________________________________________________________ _ PORTFOLIO 3 _ MODERATE Global/International 10% SP Jennison International Growth Portfolio1 Small/Mid Cap 15% Pioneer Mid-Cap Value VCT Portfolio1 Large Cap Growth 20% Fidelity VIP Growth Portfolio1 Large Cap Value 20% ING T. Rowe Price Equity Income Portfolio1 Bonds 35% ING PIMCO Core Bond Portfolio1,2 ________________________________________________________________________________ _ PORTFOLIO 4 _ MODERATELY AGGRESSIVE Global/International 15% SP Jennison International Growth Portfolio1 Small/Mid Cap 20% Pioneer Mid-Cap Value VCT Portfolio1 5% ING JPMorgan SmallCap Equity Portfolio1 Large Cap Growth 25% Fidelity VIP Growth Portfolio1 Large Cap Value 20% ING T. Rowe Price Equity Income Portfolio1 Bonds 15% ING PIMCO Core Bond Portfolio1,2 ________________________________________________________________________________ _ PORTFOLIO 5 _ AGGRESSIVE Global/International 20% SP Jennison International Growth Portfolio1 Small/Mid Cap 20% Pioneer Mid-Cap Value VCT Portfolio1 10% ING JPMorgan Small Cap Equity Portfolio1 Large Cap Growth 30% Fidelity VIP Growth Portfolio1 Large Cap Value 20% ING T. Rowe Price Equity Income Portfolio1 ________________________________________________________________________________ If you wish to participate in account rebalancing, please complete section 12. ________________________________________________________________________________ 1 The available share class is subject to distribution and/or service (12b-1) fees. 2 Transfers to and from and amounts invested in these portfolios may affect death benefit and living benefit guarantees. ________________________________________________________________________________ GA-CDF-1109 Page 7 of 10 126030 11/01/2003 ________________________________________________________________________________ 12 OPTIONAL AUTOMATIC PROGRAMS ________________________________________________________________________________ OPTIONAL SYSTEMATIC PARTIAL WITHDRAWALS (Select one below) To have your withdrawals deposited into your bank account, please complete the bank account information below. _ Maximum Amount available free of deferred sales charge. _ Specified Systematic Payment $__________ ($100.00 Minimum) _ Specified Percentage _____________% Frequency: _ Monthly _ Quarterly _ Annually Day of Month Beginning the month of Year -------------------------------------------------------------------------------- Withdrawals must wait 30 days after the investment date to begin. _ Check here if you want the Company to process the first withdrawal on the earliest date after the initial payment has been received. All subsequent payments will be processed on the date provided above. _ Check here if you do not wish to reduce the dollar amount of this withdrawal in the event of a surrender charge. (Please note that your initial dollar amount cannot be higher than the maximum allowed. Going over the maximum allowed may incur a surrender charge and may have an adverse effect on the death benefit amounts). ________________________________________________________________________________ OPTIONAL ACCOUNT REBALANCING PROGRAM (May not use with DCA) Automatic Allocation Rebalancing will occur on the last business day of the next scheduled rebalancing date. Please consult your prospectus for details regarding this feature as well as restrictions, minimum or maximum limitations, fees and other applicable information. Automatic Allocation Rebalancing does not apply to the Fixed Allocation(s) and cannot be elected if you participate in Dollar Cost Averaging. The percentages will be proportionally recalculated for subsequent reallocations if you have chosen a Fixed Allocation Election. Any subsequent reallocation, add-on or partial withdrawal you direct, other than on a pro rata basis, will terminate this program. Please rebalance my portfolio to the allocations on this form: _ Quarterly _ Semi-Annually _ Annually ________________________________________________________________________________ OPTIONAL PRE-AUTHORIZED PAYMENT PLAN (Complete bank account information below) I understand that all payments made will be allocated pro rata according to the initial allocations entered on this form. I understand and agree to indemnify the Company for any costs incurred should there be insufficient funds in the below listed account. I further understand that the Company may sell sufficient investments in the divisions underlying my contract to recover the full amount of the debit entry. Deduction Frequency: _ Monthly _ Quarterly _ Annually Amount:$_____________________________ Start Date_____________________________ ________________________________________________________________________________ BANK ACCOUNT INFORMATION Please verify this information with your bank bank prior to submission. I hereby authorize the Company to initiate a debit/credit entry(ies) to the account indicated below and in the amount and frequency listed above.This authorization shall remain in force until I give the Company written notice of termination of this authorization. A voided check or savings account deposit slip is required. Bank Account Owner Name_________________________________________________________ Bank Account Joint Owner Name (if applicable)___________________________________ Bank Name__________________________ Bank Telephone Number_______________________ Bank Address____________________________________________________________________ City_______________________________ State______________________ Zip_____________ ABA/Routing Number_________________ Account Number______________________________ _Checking Account_ Savings Account --------------------------------------- |ATTACH VOIDED CHECK/ DEPOSIT SLIP HERE| --------------------------------------- ________________________________________________________________________________ GA-CDF-1109 Page 8 of 10 126030 11/01/2003 ________________________________________________________________________________ 13 STATE REQUIRED NOTICES Below are notices that apply only in certain states. Please read the following carefully to see if any apply in your state. Colorado, Kentucky, Louisiana, New Mexico, Ohio, Oklahoma, Pennsylvania: "Any person who knowingly and with intent to defraud any insurance company or any other person, files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act which is a crime and subjects such person to criminal and civil penalties." California: For your protection, California law requires the following notice: "Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in a state prison." California Reg. 789.8: The sale or liquidation of any asset in order to buy insurance, either life insurance or an annuity contract, may have tax consequences. Terminating any life insurance policy or annuity contract may have early withdrawal penalties or other costs or penalties, as well as tax consequences. You may wish to consult independent legal or financial advice before the sale or liquidation of any asset and before the purchase of any life insurance or annuity contract. Arkansas, Florida: "Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison." Maine, Tennessee and Washington DC: "It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefits." New Jersey: "Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties." Virginia: "A person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated the state law." ________________________________________________________________________________ 14 SIGNATURES AND ACKNOWLEDGEMENTS (Please read carefully and sign below) By signing below, I acknowledge receipt of the Prospectus. I agree that, to the best of my knowledge and belief, all statements and answers in this form are complete and true and may be relied upon in determining whether to issue the applied for variable annuity. Only the owner and Golden American Life Insurance Company have the authority to modify this form. Variable Annuities and the underlying series shares or securities which fund them are not insured by the FDIC or any other agency. They are not deposits or other obligations of any bank and are not bank guaranteed. They are also subject to market fluctuation, investment risk and possible loss of principal invested. I understand that when based on the investment experience of the Separate Account Division, the variable annuity cash surrender values may increase or decrease on any day and that no minimum value is guaranteed. The variable annuity applied for is in accord with my anticipated financial objectives. I understand that the value allocated to any Account subject to a Market Value Adjustment may increase or decrease if surrendered or withdrawn prior to a specified date(s) as stated in the contract. My signature certifies, under penalty of perjury, that the taxpayer identification number provided is correct. Unless and until you are otherwise notified, I am not subject to backup withholding because: I am exempt; or I have not been notified that I am subject to backup withholdings resulting from failure to report all interest dividends; or I have been notified that I am no longer subject to backup withholding. (Strike out the preceding sentence if subject to backup withholding.) The IRS does not require my consent to any provision of this document other than the certifications required to avoid backup withholding. Owner Signature_________________________________________________________________ Signed at (City, State)__________________________________ Date__________________ Joint Owner Signature (if applicable)___________________________________________ Signed at (City, State)__________________________________ Date__________________ Annuitant Signature (If other than owner)_______________________________________ Signed at (City, State)__________________________________ Date__________________ ________________________________________________________________________________ GA-CDF-1109 Page 9 of 10 126030 11/01/2003 ________________________________________________________________________________ 15 AGENT INFORMATION Do you have reason to believe that the contract applied for will replace any existing annuity or life insurance coverage? _ Yes _ No (If "Yes", return with this form a completed copy of any state replacement form(s), if applicable.) Premium Plus Only: _ Producer Contract _ ING Employee Contract Compensation Alternative (select one-please verify with your Broker/Dealer that the option you select is available): _ A _ B _ C _ D _ E _ Check here if there are multiple agents on this contract. Split: for Agent #1____________%, Agent #2____________%, Agent #3____________% Please Note: Compensation will be split equally if no percentage is indicated. Agent #1 will receive all correspondence regarding the policy. AGENT #1 Print Name__________________________________ Signature__________________________ SSN_________________________________________ Agent Phone________________________ FL License #/Broker Code____________________ Broker/Dealer Branch_______________ AGENT #2 Print Name Signature Print Name__________________________________ Signature__________________________ SSN_________________________________________ Agent Phone________________________ FL License #/Broker Code____________________ Broker/Dealer Branch_______________ AGENT #3 Print Name__________________________________ Signature__________________________ SSN_________________________________________ Agent Phone________________________ FL License #/Broker Code____________________ Broker/Dealer Branch_______________ ________________________________________________________________________________ 16 SPECIAL REMARKS 16 ________________________________________________________________________________ GA-CDF-1109 Page 10 of 10 126030 11/01/2003