Enrollment Form for Deferred Combination Variable and Fixed Annuity – ReliaStar Life Insurance Company of New York

Contract Categories: Business Finance › Subscription Agreements
Summary

This enrollment form is used by individuals to apply for a deferred combination variable and fixed annuity with ReliaStar Life Insurance Company of New York. The form collects information about the owner, annuitant, beneficiaries, and premium allocation among various investment options. Applicants select death benefit options and specify how their initial premium should be invested. The form also allows for the designation of contingent annuitants and beneficiaries. It is a required document to initiate an annuity contract with ReliaStar.

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EX-4.V 28 newenrol.txt ENROLLMENT FORM (NEW) RELIASTAR FLEXIBLE PREMIUM LIFE INSURANCE COMPANY OF NEW YORK DEFERRED COMBINATION VARIABLE AND FIXED ANNUITY ENROLLMENT FORM RELIASTAR LIFE INSURANCE COMPANY OF NEW YORK IS A STOCK COMPANY DOMICILED IN NEW YORK - --------------------------------------------------------------------------- 1. OWNER(S) - --------------------------------------------------------------------------- Name Male Female Soc. Sec. # or Tax ID.# / / / / - --------------------------------------------------------------------------- Permanent Address Phone ( ) - --------------------------------------------------------------------------- City State Zip Date of Birth - --------------------------------------------------------------------------- 2. ANNUITANT (IF OTHER THAN OWNER) - --------------------------------------------------------------------------- Name Male Female Soc. Sec. # or Tax ID.# / / / / - --------------------------------------------------------------------------- Permanent Address Phone ( ) - --------------------------------------------------------------------------- City State Zip Date of Birth Relation to Owner =========================================================================== CONTINGENT ANNUITANT (OPTIONAL) - --------------------------------------------------------------------------- Name Address Relation to Owner - --------------------------------------------------------------------------- 3. PRIMARY BENEFICIARY(IES) (IF MORE THAN ONE - INDICATE %) - --------------------------------------------------------------------------- Name(s) Relation to Owner - --------------------------------------------------------------------------- CONTINGENT BENEFICIARY(IES) Name Relation to Owner - --------------------------------------------------------------------------- 4. PLAN - --------------------------------------------------------------------------- / / DVA PLUS - --------------------------------------------------------------------------- 5. DEATH BENEFIT OPTIONS - --------------------------------------------------------------------------- / / Annual Ratchet / / Standard - --------------------------------------------------------------------------- 6. INITIAL PREMIUM AND ALLOCATION INFORMATION - --------------------------------------------------------------------------- (A) INITIAL PREMIUM PAID $__________ Make check payable to reliastar life insurance company of New York. Fill in percentages for premium allocation below (see INITIAL) (B) CHARGE DEDUCTION DIVISION: Optional. Please check box to elect. / /
- ------------------------------------------------------------------------------------- ACCOUNT DIVISION INVESTMENT ADVISER (A) INITIAL - ------------------------------------------------------------------------------------- CAPITAL APPRECIATION A I M CAPITAL MANAGEMENT,INC. % - ------------------------------------------------------------------------------------- STRATEGIC EQUITY A I M CAPITAL MANAGEMENT,INC. % - ------------------------------------------------------------------------------------- CAPITAL GROWTH ALLIANCE CAPITAL MANAGEMENT,LP % - ------------------------------------------------------------------------------------- DEVELOPING WORLD BARING INTERNATIONAL INVESTMENT LIMITED % - ------------------------------------------------------------------------------------- HARD ASSETS BARING INTERNATIONAL INVESTMENT LIMITED % - ------------------------------------------------------------------------------------- LARGE CAP VALUE CAPITAL GUARDIAN TRUST COMPANY % - ------------------------------------------------------------------------------------- MANAGED GLOBAL CAPITAL GUARDIAN TRUST COMPANY % - ------------------------------------------------------------------------------------- SMALL CAP CAPITAL GUARDIAN TRUST COMPANY % - ------------------------------------------------------------------------------------- VALUE EQUITY EAGLE ASSET MANAGEMENT,INC. % - ------------------------------------------------------------------------------------- DIVERSIFIED MID-CAP FIDELITY MANAGEMENT &RESEARCH COMPANY % - ------------------------------------------------------------------------------------- ASSET ALLOCATION GROWTH FIDELITY MANAGEMENT & RESEARCH COMPANY % - ------------------------------------------------------------------------------------- INTERNET TOLLKEEPER GOLDMAN SACHS ASSET MANAGEMENT % - ------------------------------------------------------------------------------------- PILGRIM VP GROWTH OPPORTUNITIES ING PILGRIM INVESTMENTS,LLC % - ------------------------------------------------------------------------------------- PILGRIM VP MAGNACAP ING PILGRIM INVESTMENTS,LLC % - ------------------------------------------------------------------------------------- PILGRIM VP SMALLCAP OPPORTUNITIES ING PILGRIM INVESTMENTS,LLC % - ------------------------------------------------------------------------------------- PILGRIM WORLDWIDE GROWTH ING PILGRIM INVESTMENTS,LLC % - ------------------------------------------------------------------------------------- GALAXY VIP ASSET ALLOCATION FLEET INVESTMENT ADVISOR,INC. % - ------------------------------------------------------------------------------------- GALAXY VIP EQUITY FLEET INVESTMENT ADVISOR,INC. % - ------------------------------------------------------------------------------------- GALAXY VIP GROWTH & INCOME FLEET INVESTMENT ADVISOR,INC. % - ------------------------------------------------------------------------------------- GALAXY VIP HIGH QUALITY BOND FLEET INVESTMENT ADVISOR,INC. % - ------------------------------------------------------------------------------------- GALAXY VIP SMALL COMPANY GROWTH FLEET INVESTMENT ADVISOR,INC. % - ------------------------------------------------------------------------------------- LIMITED MATURITY BOND ING INVESTMENT MANAGEMENT,LLC % - ------------------------------------------------------------------------------------- LIQUID ASSET ING INVESTMENT MANAGEMENT,LLC % - ------------------------------------------------------------------------------------- GROWTH JANUS CAPITAL CORPORATION % - ------------------------------------------------------------------------------------- GROWTH AND INCOME JANUS CAPITAL CORPORATION % - ------------------------------------------------------------------------------------- SPECIAL SITUATIONS JANUS CAPITAL CORPORATION % - ------------------------------------------------------------------------------------- PRUDENTIAL JENNISON JENNISON ASSOCIATES LLC % - ------------------------------------------------------------------------------------- SP JENNISON INTERNATIONAL GROWTH JENNISON ASSOCIATES LLC % - ------------------------------------------------------------------------------------- RISING DIVIDENDS KAYNE ANDERSON RUDNIK INVESTMENT MANAGEMENT,LLC % - ------------------------------------------------------------------------------------- MID-CAP GROWTH MASSACHUSETTS FINANCIAL SERVICES COMPANY % - ------------------------------------------------------------------------------------- RESEARCH MASSACHUSETTS FINANCIAL SERVICES COMPANY % - ------------------------------------------------------------------------------------- TOTAL RETURN MASSACHUSETTS FINANCIAL SERVICES COMPANY % - ------------------------------------------------------------------------------------- CORE BOND PACIFIC INVESTMENT MANAGEMENT COMPANY % - ------------------------------------------------------------------------------------- PIMCO HIGH YIELD BOND PACIFIC INVESTMENT MANAGEMENT COMPANY % - ------------------------------------------------------------------------------------- PIMCO STOCKSPLUS GROWTH & INCOME PACIFIC INVESTMENT MANAGEMENT COMPANY % - ------------------------------------------------------------------------------------- PROFUND VP BULL PROFUND ADVISORS,LLC % - ------------------------------------------------------------------------------------- PROFUND VP SMALL CAP PROFUND ADVISORS,LLC % - ------------------------------------------------------------------------------------- PROFUND VP EUROPE 30 PROFUND ADVISORS,LLC % - ------------------------------------------------------------------------------------- REAL ESTATE PRUDENTIAL INVESTMENT CORPORATION % - ------------------------------------------------------------------------------------- ALL CAP SALOMON BROTHERS ASSET MANAGEMENT INC. % - ------------------------------------------------------------------------------------- INVESTORS SALOMON BROTHERS ASSET MANAGEMENT INC. % - ------------------------------------------------------------------------------------- EQUITY INCOME T.ROWE PRICE ASSOCIATES,INC. % - ------------------------------------------------------------------------------------- FULLY MANAGED T.ROWE PRICE ASSOCIATES,INC. % - ------------------------------------------------------------------------------------- FIXED ALLOCATIONS: o 1 YR o 3 YR o 5 YR o 7 YR o 10 YR % - ------------------------------------------------------------------------------------- TOTAL 100% - -------------------------------------------------------------------------------------
RELIASTAR LIFE INSURANCE COMPANY OF NEW YORK, VARIABLE PRODUCT CUSTOMER SERVICE CENTER 1475 Dunwoody Drive West Chester, PA 19380 ###-###-#### FG-EA-1000-08/97 (PE) 08/24/2001 000000 - --------------------------------------------------------------------------- 7. OPTIONAL SYSTEMATIC PARTIAL WITHDRAWALS - --------------------------------------------------------------------------- If you want to receive Systematic Partial Withdrawals, your request must be received in writing. For the appropriate form, please call our Customer Service Center: 1 ###-###-####. - --------------------------------------------------------------------------- 8. TAX-QUALIFIED PLANS If you are funding a qualified plan, please specify type: - --------------------------------------------------------------------------- / / IRA / / IRA Rollover / / SEP/IRA / /Other _______________ - --------------------------------------------------------------------------- 9. REPLACEMENT Will the coverage applied for replace any existing annuity or life insurance policies on the annuitant's life? - --------------------------------------------------------------------------- / / Yes (If yes, please complete following.) / / No - --------------------------------------------------------------------------- Company Name Policy Number Face Amount - --------------------------------------------------------------------------- - --------------------------------------------------------------------------- 10. READ THE FOLLOWING STATEMENTS CAREFULLY AND SIGN BELOW: - --------------------------------------------------------------------------- o 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 SEPARATE ACCOUNT DIVISION, 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 IN ACCORD WITH MY ANTICIPATED FINANCIAL NEEDS. o I AGREE 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. MY ANSWERS WILL FORM A PART OF ANY CONTRACT TO BE ISSUED, AND ONLY THE OWNER AND RELIASTAR HAVE THE AUTHORITY TO MODIFY THIS APPLICATION. o CONTRACTS AND POLICIES AND UNDERLYING SERIES SHARES OR SECURITIES WHICH FUND 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. ALSO, THEY ARE SUBJECT TO MARKET FLUCTUATION, INVESTMENT RISK AND POSSIBLE LOSS OF PRINCIPAL INVESTED. - ------------------------------- ------------------------------------ Signature of Owner Signed at (City, State) Date - ------------------------------- ------------------------------------ Signature of Joint Owner (if applicable) Signed at (City, State) Date - ------------------------------- ------------------------------------ Signature of Annuitant Signed at (City, State) Date (if other than Owner) Client Account No. (if applicable)_____________________ - --------------------------------------------------------------------------- FOR AGENT USE ONLY DO YOU HAVE REASON TO BELIEVE THAT THE COVERAGE APPLIED FOR WILL REPLACE ANY EXISTING ANNUITY OR LIFE INSURANCE ON THE ANNUITANT'S LIFE? / / Yes / / No - --------------------------------------------------------------------------- - ------------------------------ ------------------------------ Agent Signature Print Agent Name & No. - ------------------------------ --------------------------------- Social Security No. Broker/Dealer/Branch Amendment to Application - --------------------------------------------------------------------------- - --------------------------------------------------------------------------- - --------------------------------------------------------------------------- - --------------------------------------------------------------------------- - --------------------------------------------------------------------------- RELIASTAR LIFE INSURANCE COMPANY OF NEW YORK, VARIABLE PRODUCT CUSTOMER SERVICE CENTER 1475 Dunwoody Drive West Chester, PA 19380 ###-###-#### FG-EA-1000-08/97 (PE) 08/24/2001 000000