EX-99.B5A 7 gacdf3002.txt CUSTOMER DATA FORM Variable Annuities ING INCOME GENERATION ANNUITY SINGLE PREMIUM IMMEDIATE ANNUITY CUSTOMER DATA FORM ING USA Annuity and Life Insurance Company Service Office: P.O. Box 9271, Des Moines, IA 50306-9271 Overnight Address: 909 Locust Street, Des Moines, IA 50309-2899 Phone: 800-366-0066 FOR AGENT USE ONLY: Client's Account Number:________________________________________________________ 1 OWNER Name:______________________________________________Trust Date:__________________ SSN or Tax ID:____________________Date of Birth:_______________ __Male __Female Permanent Address:__________________City:_____________State:_______ Zip:________ Telephone: Home:______________Work:_____________EMail Address:__________________ 1(a)JOINT OWNER (Optional. Non-Qualified Plans Only. Option Package I only.) Name:______________________________________________Trust Date:__________________ SSN or Tax ID:____________________Date of Birth:_______________ __Male __Female Permanent Address:__________________City:_____________State:_______ Zip:________ Telephone: Home:______________Work:_____________EMail Address:__________________ 2 ANNUITANT (If other than owner. For Qualified contracts, must be the same as the owner. Annuitant may not be changed.) Name:______________________________________________Trust Date:__________________ SSN or Tax ID:____________________Date of Birth:_______________ __Male __Female Permanent Address:__________________City:_____________State:_______ Zip:________ 2(a) CONTINGENT ANNUITANT (Optional. The Owner is the Contingent Annuitant unless someone else is names.) Name:______________________________________________Trust Date:__________________ SSN or Tax ID:____________________Date of Birth:_______________ __Male __Female Permanent Address:__________________City:_____________State:_______ Zip:________ GA-CDF-3002 Page 1 of 9 132770 10/21/2004 3 BENEFICIARY(S) (Must be completed.) PRIMARY BENEFICIARY Name:___________________________________Date of Birth:________________ ________% SSN or Tax ID:__________________________Relationship to Owner:__________________ Address:________________________________________________________________________ __PRIMARY __CONTINGENT BENEFICIARY Name:___________________________________Date of Birth:________________ ________% SSN or Tax ID:__________________________Relationship to Owner:__________________ Address:________________________________________________________________________ __PRIMARY __CONTINGENT BENEFICIARY Name:___________________________________Date of Birth:________________ ________% SSN or Tax ID:__________________________Relationship to Owner:__________________ Address:________________________________________________________________________ __PRIMARY __CONTINGENT BENEFICIARY Name:___________________________________Date of Birth:________________ ________% SSN or Tax ID:__________________________Relationship to Owner:__________________ Address:________________________________________________________________________ For additional Beneficiary designations, please use the space provided in section 16. If no percentages are provided, beneficiary proceeds will be split equally. 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(s) 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 Estate 100% Trust ABC Trust Trust 100% Dtd 1/1/85 Testamentary Trust Trust created by the Testamentary Trust 100% (Trust established Last Will and within the owner's will) Testament of John Doe GA-CDF-3002 Page 2 of 9 132770 10/21/2004 4 INITIAL INVESTMENT Please make any checks payable to ING USA Annuity and Life Insurance Company. __Initial Premium Paid:$______________________________________________________ __Estimated amount of Transfer/1035 Exchange:$________________________________ 5 PRODUCT SELECTION PRODUCT _X_ ING Income Generation Annuity ANNUITY OPTIONS (Please select one Annuity Option only.) For an IRA, 401(k), 403(b) or 457 Government Contract the Annuity Option elected must comply with IRC 401(a)(9) Regulations. Unless spousal consent is provided, contracts subject to ERISA must elect the Joint Lifetime Option. NON-LIFETIME OPTION __A. Period Certain of:________ (5-50 Years)1 (5-30 Years for Fixed Payments)1 SINGLE LIFETIME OPTIONS2 __B. Single Life Only __C. Single Life with Guaranteed payments for:________ (5-50 Years)1 (5-30 Years for Fixed Payments)1 JOINT LIFETIME OPTIONS2 __D. Joint & 100% Survivor __E. Joint & 100% Survivor with Guaranteed payments for:________(5-50 Years)1 (5-30 Years for Fixed Payments)1 __F. Joint & 75% Survivor __G. Joint & 662/3% Survivor __H. Joint & 50% Survivor __I. Joint & 75% Contingent Survivor __J. Joint & 662/3% Contingent Survivor __K. Joint & 50% Contingent Survivor 1 Guaranteed Payment Periods cannot exceed age 100 for non-qualified contracts, or the lesser of age 100 and life expectancy for qualified contracts. 2 REQUIRED DOCUMENTATION NOTICE: With all lifetime annuity options satisfactory evidence of date of birth of the Annuitant and Joint Annuitant (if applicable) must be provided. A copy of the birth certificate or valid driver's license is acceptable. If the birth certificate or valid driver's license is not available, we will accept copies of two federally recognized forms of identification that include the date of birth. PAYMENT OPTIONS (Please select one Payment Option only.) __100% Fixed Payments __100% Variable Payment __Combination Variable/Fixed Payments (Indicate allocation of 1% - 99%) Fixed:_____________% Variable:_____________% Do the percentages allocated to variable and fixed payments total 100%? Assumed Annual Interest Rate (AIR). Not available with 100% Fixed payments. (Select one) __3% __5% (3% will be assumed if no election is made. If the Guaranteed Minimum Income Benefit is elected, only an AIR of 3% is allowed.) Frequency: __Monthly __Quarterly __Semi-Annually __Annually Day of Month_______ Beginning the month of__________ Year_________ GA-CDF-3002 Page 3 of 9 132770 10/21/2004 6 VARIABLE PAYMENT OPTIONAL FEATURES Select Variable investment Options on page 6. __Right to Withdraw Privileges1 Available with Annuity Options A, C and E. Note: this option is automatically included with Annuity Option A where some or all of the Premium has been allocated to Variable Payments. With Annuity Option A the Flexible Period Option2 is automatically added when Right to Withdraw Privileges is elected. __Guaranteed Minimum Income Rider This Benefit, when elected, guarantees that for the first 5 years your variable payment will never be less than 90% of your initial estimated variable annuity payment. In order to elect this option, the Assumed Interest Rate must be 3% and the total Premium applied to Variable Payments must equal 100%. Available with Annuity Option A with Guaranteed Payments of 15 years or more; Annuity Option B; Annuity Option C with Guaranteed Payments of 15 years or more, unless you have elected Right To Withdraw Privileges; and Annuity Options D and E. 1 Withdrawals may be subject to Surrender Charges. Withdrawals are not available during the first contract year or before the First Annuity Payment Date, if that date is later than the first contract anniversary. Thereafter, only one withdrawal is allowed annually. However, this does not apply to withdrawals from the variable portion of a Period Certain Annuity (Annuity Option A). Refer to the prospectus for additional information about this option. 2 When elected, the Flexible Period Option may not be exercised until the second contract anniversary, and then only on each contract anniversary thereafter. If you have also elected the Guaranteed Minimum Income Benefit Rider, this option may not be exercised until 5 years have elapsed since the Contract Date. Refer to the Prospectus for additional information about this option. 7 FIXED PAYMENT OPTIONAL FEATURES __Right to Withdraw Privileges3 Available with Annuity Options A, C and E. Not available with the Increasing Fixed Annuity Payment Option or Cash Refund Option shown below. With Annuity Option A the Flexible Period Option4 is automatically added when Right to Withdraw Privileges is elected. __Increasing Fixed Annuity Payment Option Annual Increase Percentage (Select one) __1% __2% __3% This feature is available with Annuity Options A, B, C, D and E. In order to elect this option, total Premium applied to Fixed Payments must equal 100%. Not available with Right to Withdraw Privileges or the Cash Refund Option. Refer to the Prospectus for additional information associated with this option. __Cash Refund Option Available only with Annuity Options B and D. Not available with the Right to Withdraw Privileges or the Increasing Fixed Annuity Payment Option. Refer to the Prospectus for additional information about this option. 3 Withdrawals may be subject to a Market Value Adjustment and Surrender Charges. Withdrawals are not available during the first contract year or before the First Annuity Payment Date, if that date is later than the first contract anniversary. Thereafter, only one withdrawal is allowed annually. However, this does not apply to withdrawals from the variable portion of a Period Certain Annuity (Annuity Option A). Refer to the prospectus for additional information about this option. 4 When elected, the Flexible Period Option may not be exercised until the second contract anniversary and then only on each contract anniversary thereafter. Refer to the Prospectus for additional information about this option. GA-CDF-3002 Page 4 of 9 132770 10/21/2004 8 TELEPHONE REALLOCATION AUTHORIZATION I authorize ING USA Annuity and Life Insurance Company (the Company) to act upon reallocation instructions, given by electronic means or voice command from the agent named in section 14 and/or the following individuals listed below upon furnishing their Social Security Number or alternative identification number. To authorize the agent, the Owner must initial:_____________________ Provide the name and Social Security Number of other authorized individuals below1: 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 if the Company or authorized person acts in good faith in reliance upon this authorization in connection with oral/electronic instructions. 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. The Company may discontinue or limit this privilege at any time. 1If the authorized person's Social Security Number is not provided, the individual will not be authorized. 9 PLAN TYPE FOR NEW CONTRACT (Qualified or Non-Qualified. Please select only one.) __Non-Qualified __1035 Exchange __IRA __IRA Transfer __IRA Rollover from Qualified Plan __SEP-IRA __403(b) __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:________ 10 IMPORTANT NOTICE REGARDING REPLACEMENT Do you currently have any existing annuity or life insurance policies or coverage? __Yes (Proceed below.) __No (Proceed to section 11.) 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 the appropriate 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-3002 Page 5 of 9 132770 10/21/2004 11 VARIABLE INVESTMENT OPTIONS Complete this section if 100% Variable Payments or Combination Variable/Fixed Payments is elected. Variable Investment Allocations are not required and will not be processed if 100% Fixed Payments is elected. VARIABLE ALLOCATIONS Use whole percentages only. __% AIM V.I. Dent Demographic Trends 1,2 __% ING MFS Mid Cap Growth1,2 __% Colonial Small Cap Value __% ING MFS Research1,2 __% Fidelity VP Equity-Income1 __% ING MFS Total Return1 __% Fidelity VP Growth1 __% ING PIMCO High Yield1 __% ING AM Mid Cap Growth1 __% ING PIMCO Core Bond1 __% ING Alliance Mid Cap Growth1,2 __% ING Salomon Bros Aggr Growth1 __% ING American Funds Growth1 __% ING Salomon Bros All Cap1 __% ING American Funds Growth-Income1 __% ING Salomon Bros Investors 1,2 __% ING American Funds Int'l1 __% ING T. Rowe Price Capital Appr1 __% ING Cap Guardian Large Cap1,2 __% ING T. Rowe Price Equity Income1 __% ING Cap Guardian Managed Global1 __% ING UBS US Balanced1 __% ING Cap Guardian Small Cap1 __% ING VP Bond1 __% ING Developing Word1 __% SP William Blair Int'l Growth1 __% ING Eagle Asset Capital Appr1,2 __% ING VP Financial Services1 __% ING Evergreen Heath Sciences1 __% ING VP Index Pus LargeCap1 __% ING Evergreen Omega1 __% ING VP Index Pus MidCap1 __% ING FMR Diversified Mid Cap1 __% ING VP Index Pus SmallCap1 __% ING Goldman Sachs Tollkeeper1,2 __% ING VP Magnacap1 __% ING Hard Assets1 __% ING VP MidCap Opportunities1,2 __% ING International1 __% ING VP SmallCap Opportunities1 __% ING Janus Special Equity1 __% ING VP Worldwide Growth1 __% ING Jennison Equity Opp1 __% ING Van Kampen Equity Growth1 __% ING JPMorgan Fleming Int'l1 __% ING Van Kampen Global Franchise1 __% ING JPMorgan Small Cap Equity1 __% ING Van Kampen Growth and Income1 __% ING Julius Baer Foreign1 __% ING Van Kampen Real Estate1 __% ING Legg Mason Value1 __% INVESCO VF Leisure Fund1 __% ING Lifestyle Aggressive Growth1 __% INVESCO VF Utilities Fund1 __% ING Lifestyle Growth Portfolio1 __% Jennison Portfolio1,2 __% ING Lifestyle Moderate Growth1 __% Pioneer Fund VCT1 __% ING Lifestyle Moderate1 __% Pioneer Mid-Cap Value VCT1 __% ING Liquid Assets1 __% ProFund VP Bull __% ING Marsico Growth1 __% ProFund VP Europe 30 __% ING Mercury Focus Value1,2 __% ProFund VP Rising Rates Opp1,2 __% ING Mercury Fundamental Growth __% ProFund VP Small-Cap 100% Variable Allocation Total Do the variable allocations total 100%? 1The available share class is subject to distribution and/or service (12b-1) fees. 2 These funds are not available if the Guaranteed Minimum Income Benefit is elected. GA-CDF-3002 Page 6 of 9 132770 10/21/2004 12 PAYMENT OPTIONS Please complete and return a Withholding Certificate of Pension or Annuity Payments (Form W-4P) with this Customer Data Form. A check will be made payable to the owner and mailed to owner's address (as entered on page 1 of the application) unless otherwise instructed below. __By check payable to the order of another party. (Complete Alternate Payee Information below.) __Direct Deposit to a Financial Institution. (Complete Bank Account Information below.) ALTERNATE PAYEE INFORMATION Name:___________________________________________________________________________ SSN/TIN:__________________________________________________DOB:__________________ Address:________________________________________________________________________ City:_______________________________State:________________Zip:__________________ Telephone Number:Day:_____________________Evening:______________________________ BANK ACCOUNT INFORMATION (Please verify this information with your 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:___________________ __Checking Account __Savings Account ABA/Routing Number:___________________Account Number:___________________________ ATTACH VOIDED CHECK/ DEPOSIT SLIP HERE GA-CDF-3002 Page 7 of 9 132770 10/21/2004 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. Arkansas and Louisiana: "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." Colorado, Kentucky, New Mexico, Ohio, Oklahoma, and 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. Florida: "Any person who knowingly with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. 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 ING USA Annuity and 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, amounts invested in the variable separate account divisions 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 any amounts withdrawn from Fixed Annuity Payments will be subject to a Market Value Adjustment. 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 at1 (City, State):_____________________________________Date:_____________ Joint Owner Signature (If applicable):__________________________________________ Signed at1 (City, State):_____________________________________Date:_____________ Annuitant Signature (If other than owner):______________________________________ Signed at1 (City, State):_____________________________________Date:_____________ 1If this Customer Data Form is being signed in a state other than the Owner's resident state, please indicate the reason in the special remarks section. If you have any questions on what is an acceptable reason, please refer to the Nexis Information Worksheet. GA-CDF-3002 Page 8 of 9 132770 10/21/2004 16 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 the appropriate state replacement form(s), if applicable.) Compensation Alternative (Select one- please verify with your Broker/Dealer that the option you select is available.): __A __B __C __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 percentages are indicated. Partial percentages will be rounded up and Agent #1 will be given the highest percentage in the case of unequal percentages. Agent #1 will receive all correspondence regarding the policy. AGENT #1 Print Name:______________________________Signature:_____________________________ SSN:_____________________________________Agent Phone:___________________________ License #________________________________Broker Code:___________________________ Broker/Dealer Branch:___________________________________________________________ AGENT #2 Print Name:______________________________Signature:_____________________________ SSN:_____________________________________Agent Phone:___________________________ License #________________________________Broker Code:___________________________ Broker/Dealer Branch:___________________________________________________________ AGENT #3 Print Name:______________________________Signature:_____________________________ SSN:_____________________________________Agent Phone:___________________________ License #________________________________Broker Code:___________________________ Broker/Dealer Branch:___________________________________________________________ 17 SPECIAL REMARKS GA-CDF-3002 Page 9 of 9 132770 10/21/2004