Individual Annuity Application between Applicant and ReliaStar Life Insurance Company of New York

Summary

This document is an application for an individual variable annuity contract offered by ReliaStar Life Insurance Company of New York. The applicant provides personal and beneficiary information, selects contract type (qualified or non-qualified), chooses investment options, and specifies payment details. The contract allows for various investment allocations and optional benefits, with terms and conditions outlined in the prospectus. The agreement becomes effective upon acceptance by the insurer and receipt of payment.

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EX-4.C 9 applsdva.txt INDIVIDUAL ANNUITY APPLICATION ING [Logo] Reliastar Life Insurance Company of New York P.O. Box 2700 West Chester, PA ###-###-#### Phone: (800) 366-0066 Express Mail: ING ANNUITIES, 1475 Dunwoody Drive, West Chester, PA 19380 ING SMARTDESIGN VARIABLE ANNUITY- NEW YORK CUSTOMER DATA FORM CONTRACT INFORMATION - -------------------------------------------------------------------------------- TYPE OF CONTRACT NON-QUALIFIED __Regular __1035 Exchange* QUALIFIED A.__Initial ___Transfer* __Rollover* B.__IRA __403(b) __Roth IRA __IRA to Roth IRA __SEP-IRA __Other __________________________ C.__Individual ___Custodial Tax Year for which contribution is being made _______________________ *Please attach required additional forms. Option Package: (select one) __Option Package I __Option Package II** __Option Package III** Death Benefit, withdrawal options and expenses will vary depending on the Option Package chosen. Please refer to your prospectus for further details on the Option Packages available under this contract. Optional Benefits __SmartDesign Earnings Multiplier** **Not available for Joint Owners Read your prospectus for further details. PRE-AUTHORIZED CHECKING, DOLLAR COST AVERAGING AND ACCOUNT REBALANCING ARE NOT PERMITTED INTO THE GET FUND. - -------------------------------------------------------------------------------- OWNER INFORMATION OWNER __Male __Female - ---------------------------------------- Name: SSN# or Tax ID: - ---------------------------------------- Permanent Address: - ---------------------------------------- City: State: Zip: - ---------------------------------------- Date of Birth: EMail Address: - ---------------------------------------- Telephone: Home Work JOINT OWNER (Optional: Non-Qualified Only) Available with Option Package I Only ___Male ___Female - ---------------------------------------- Name: SSN# or Tax ID: - ---------------------------------------- Permanent Address: - ---------------------------------------- City: State: Zip: - ---------------------------------------- Date of Birth: EMail Address: - ---------------------------------------- Telephone: Home Work __Check box to have a 2nd statement sent to address above. ANNUITANT If other than owner (For Qualified contracts, the Annuitant must also be the owner; Note: annuitant may not be changed) __Male __Female - ---------------------------------------- Name: SSN# or Tax ID: - ---------------------------------------- Permanent Address: - ---------------------------------------- City: State: Zip: - ---------------------------------------- Date of Birth: EMail Address: - ---------------------------------------- Telephone: Home Work BENEFICIARY(IES) (Please refer to prospectus for details) Complete Legal Name Relationship Social Security No. Percentage Primary: - -------------------------------------------------------------------------------- Primary:__ Contingent:__ - -------------------------------------------------------------------------------- Primary:__ Contingent:__ - -------------------------------------------------------------------------------- PAYMENT INFORMATION __Initial Payment: $______________ Make check payable to Reliastar Life Insurance Company of New York (RLNY) __Estimated amount of transfer/1035 exchange $______________ __Pre-authorized Payment Plan - I authorize (1) RLNY to debit the account indicated on the enclosed check for the payment amount indicated on this form; and (2) the bank indicated on the enclosed check to pay RLNY and charge the account shown on the enclosed check for debits drawn and payable to RLNY as payments under this contract. (Attach check marked "VOID.") May not be available on this contract. Preferred Debit Date: ____________________ any day prior to the 28th Amount:__Monthly $_________ Quarterly $_____ __Semiannually $_____ Annually $______ RLNY-CDF-1088 Page 1 of 3 03/20/2002 122497 ALLOCATION OF INITIAL PAYMENT Variable Investment Options2 (Percentages must be in whole number) ________% AIM VI Dent Demographic Trends Fund2 ________% AIM VI Growth Fund2 ________% Alliance VP AllianceBernstein Value Portfolio2 ________% Alliance VP Growth and Income Portfolio2 ________% Alliance VP Premier Growth Portfolio2 ________% Eagle Value Equity Series ________% Fidelity VIP Equity-Income Portfolio2 ________% Fidelity VIP Growth Portfolio2 ________% Fidelity VIP II Contra fund Portfolio2 ________% ING GET Fund (when available)3 ________% ING JP Morgan Mid Cap Value Portfolio ________% ING MFS Capital Opportunities Portfolio ________% ING MFS Global Growth Portfolio ________% ING Van Kampen Comstock Portfolio ________% ING VP Convertible Portfolio2 ________% ING VP Growth & Income Portfolio ________% ING VP Index Plus LargeCap Portfolio2 ________% ING VP Index Plus MidCap Portfolio2 ________% ING VP Index Plus SmallCap Portfolio2 ________% ING VP Large Cap Portfolio ________% ING VP MagnaCap Portfolio2 ________% ING VP Value Opportunity Portfolio2 ________% ING VP Worldwide Growth Portfolio ________% International Enhances EAFE Series ________% International Equity Series ________% INVESCO VIF Financial Services Fund ________% INVESCO VIF Health Sciences Fund ________% INVESCO VIF Leisure Fund ________% INVESCO VIF Utilities Fund ________% Janus Aspen Worldwide Growth Portfolio ________% Janus Growth and Income Series2 ________% Jennison Portfolio2 ________% JP Morgan Fleming Small Cap Equity Series ________% Liquid Asset Series ________% MFS Research Series ________% MFS Total Return Series ________% PIMCO Core Bond Series ________% PIMCO VI High Yield Bond Portfolio ________% Pioneer Fund VCT Portfolio2 ________% Pioneer Small Company VCT Portfolio2 ________% Prudential SP Jennison International Growth Portfolio2 ________% Putnam VT Growth and Income Fund2 ________% Putnam VT International Growth and Income Fund2 ________% Putnam VT Voyager Fund II2 ________% UBS Tactical Asset Allocation Portfolio2 Fixed Investment Options ________% Fixed Account 6-Month DCA Term ________% Fixed Account 1-Year DCA Term ________% Fixed Account 1-Year Term ________% Fixed Account 3-Year Term ________% Fixed Account 5-Year Term ________% Fixed Account 7-Year Term ________% Fixed Account 10-Year Term ____100_% Total DOLLAR COST AVERAGING (DCA)1,2 __I elect DCA for a period of _______ months. DCA program will commence immediately following purchase payment. (6-12 mos. for the Fixed Interest Division (DCA Only).) Transfer ________________ every __Month __Quarter Source Fund: __Liquid Asset Division __1 YR Fixed DCA __6-Month Fixed DCA To the following variable investment option(s): (ENTER DOLLAR AMOUNT OR WHOLE PERCENTAGE AMOUNT.) ________ AIM VI Dent Demographic Trends Fund2 ________ AIM VI Growth Fund2 ________ Alliance VP AllianceBernstein Value Portfolio2 ________ Alliance VP Growth and Income Portfolio2 ________ Alliance VP Premier Growth Portfolio2 ________ Eagle Value Equity Series ________ Fidelity VIP Equity-Income Portfolio2 ________ Fidelity VIP Growth Portfolio2 ________ Fidelity VIP II Contra fund Portfolio2 ________ ING JP Morgan Mid Cap Value Portfolio ________ ING MFS Capital Opportunities Portfolio ________ ING MFS Global Growth Portfolio ________ ING Van Kampen Comstock Portfolio ________ ING VP Convertible Portfolio2 ________ ING VP Growth & Income Portfolio ________ ING VP Index Plus LargeCap Portfolio2 ________ ING VP Index Plus MidCap Portfolio2 ________ ING VP Index Plus SmallCap Portfolio2 ________ ING VP Large Cap Portfolio ________ ING VP MagnaCap Portfolio2 ________ ING VP Value Opportunity Portfolio2 ________ ING VP Worldwide Growth Portfolio ________ International Enhances EAFE Series ________ International Equity Series ________ INVESCO VIF Financial Services Fund ________ INVESCO VIF Health Sciences Fund ________ INVESCO VIF Leisure Fund ________ INVESCO VIF Utilities Fund ________ Janus Aspen Worldwide Growth Portfolio ________ Janus Growth and Income Series2 ________ Jennison Portfolio2 ________ JP Morgan Fleming Small Cap Equity Series ________ Liquid Asset Series ________ MFS Research Series ________ MFS Total Return Series ________ PIMCO Core Bond Series ________ PIMCO VI High Yield Bond Portfolio ________ Pioneer Fund VCT Portfolio2 ________ Pioneer Small Company VCT Portfolio2 ________ Prudential SP Jennison International Growth Portfolio2 ________ Putnam VT Growth and Income Fund2 ________ Putnam VT International Growth and Income Fund2 ________ Putnam VT Voyager Fund II2 ________ UBS Tactical Asset Allocation Portfolio2 - -------------------------------------------------------------------------------- 1 DCA does not ensure a profit or guarantee against loss in a declining market. 2 The shares of these portfolios are subject to distribution and/or service (12b-1) fees 3 Because each series of the GET Fund is a limited time offering, please note that any initial or subsequent deposits received for the GET Fund will be allocated to the series that is then available. If no series is available, your deposit will be allocated to the Liquid Asset Series, unless otherwise specified. RLNY-CDF-1088 Page 2 of 3 03/20/2002 122497 ACCOUNT REBALANCING PROGRAM __I elect the Account Rebalancing Program. (check one) __Quarterly __Semiannually __Annually With this program, amounts in the variable investment options are reallocated, as frequently as you elect above, to reflect the percentages indicated on this form. May not use DCA concurrently. ACCOUNT REBALANCING PROGRAM IS NOT PERMITTED INTO THE GET FUND. - -------------------------------------------------------------------------------- SYSTEMATIC WITHDRAWAL OPTION Amount (per year): $______________ or ______________% (up to a maximum of 10% per account year) Frequency: Monthly Quarterly Annually Start date: ____________________ (mo/yr) on the 15th or 28th Electronically deposit my payments to: Account # ____________________________ Bank Routing # ______________________________ (Please attach VOIDED check.) Federal law requires that 10% must be withheld from taxable distributions unless you elect not to have taxes withheld. You may be subject to tax penalties if your payments of estimated tax and withholding are not adequate. __I do not wish to have taxes withheld RLNY offers other Systematic Distribution Options. Please refer to the Systematic Distribution Options form. - -------------------------------------------------------------------------------- SPECIAL REMARKS - -------------------------------------------------------------------------------- DISCLOSURES AND SIGNATURES Please read the following statements carefully and sign below: *By signing below, I acknowledge receipt of the Prospectus. I understand that this contract's cash surrender value 1) when based on the investment experience of a variable investment option may increase or decrease on any day and that no minimum value is guaranteed, and 2) when based on the Fixed Account, may be subject to a Market Value Adjustment, the operation of which may cause the values to increase or decrease. This contract is consistent with my anticipated financial needs. *I certify that, to the best of my knowledge and belief, all statements and answers in this application are complete and true and may be relied upon in determining whether to issue the contract. *I understand that this contract and the underlying Series shares or securities which fund this contracts and policies 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. I also understand that they are subject to market fluctuation, investment risk and possible loss of principal invested. *My signature certifies, under penalty of perjury, that the taxpayer identification number provided is correct. 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. - -------------------------------------------------------------------------------- Signature of Owner Signed at (City, State) Date - -------------------------------------------------------------------------------- Signature of Joint Owner (If applicable) Signed at (City, State) Date - -------------------------------------------------------------------------------- Signature of Annuitant (If other than owner) Signed at (City, State) Date FOR AGENT USE ONLY Do you have reason to believe that the contract applied for will replace any existing annuity or life insurance coverage? __Yes (If yes, submit required replacement forms.) __No COMMISSION ALTERNATIVE(select one-please verify with your broker/dealer that the option you select is available): __A __B __C Client's Account Number: ________________ ------------------------------------------------------------------------ Agent Signature Print Agent Name Agent Phone Number ------------------------------------------------------------------------ Social Security # License#/Broker -Code Broker/Dealer/Branch RLNY-CDF-1088 Page 3 of 3 03/20/2002 122497