Golden American Life Insurance Company Single Premium Deferred Annuity Application
Summary
This application is for individuals seeking to purchase a single premium deferred annuity from Golden American Life Insurance Company. Applicants provide personal information, designate beneficiaries, select annuity options, and acknowledge key terms, including investment risks and tax certifications. The agreement outlines that the annuity is not FDIC insured, may fluctuate in value, and is subject to market risk. Applicants must certify the accuracy of their information and acknowledge state-specific fraud warnings. The contract becomes effective upon acceptance by the insurer and is governed by the terms specified in the final annuity contract.
EX-4.E 5 0005.txt SINGLE PREM. DEFERRED ANNUITY APPLICATION EXHIBIT 4(e) GOLDEN AMERICAN LIFE INSURANCE COMPANY MODIFIED GUARANTEED ANNUITY PO BOX 2700 WEST CHESTER, PA ###-###-#### APPLICATION PHONE: (800) 366-0066 Express Mail:ING Variable Annuities 1475 Dunwoody Drive West Chester, PA 19380 |------------------------------------------------------------------------------| |1. POLICY OWNER JOINT OWNER | | (Not applicable if qualified plan) | |Name___________________________ Name_______________________________ | |Address________________________ Address____________________________ | |City________ State___ Zip______ City__________ State_____ Zip______ | |__Male __Female __Male __Female | |Date of Birth ____/____/____ Date of Birth____/____/____ | |Social Security Number_________ Social Security Number_____________ | | | |------------------------------------------------------------------------------| |2. ANNUITANT JOINT ANNUITANT | |(If different from owner) (Not applicable if qualified plan) | |Name___________________________ Name_______________________________ | |Address________________________ Address____________________________ | |City________ State___ Zip______ City__________ State_____ Zip______ | |__Male __Female __Male __Female | |Date of Birth ____/____/____ Date of Birth____/____/____ | |Social Security Number_________ Social Security Number_____________ | |------------------------------------------------------------------------------| |3. PRIMARY BENEFICIARY(IES) | |FULL NAME(S) RELATIONSHIP TO OWNER SOCIAL SECURITY # % TO RECEIVE | |______________________________________________________________________________| | | |______________________________________________________________________________| | | |______________________________________________________________________________| |(Add separate sheet signed by policyowner for additional/contingent | |beneficiary information.) | | | |------------------------------------------------------------------------------| |4. POLICY INFORMATION | |GOLDENSELECT Guarantee Annuity | |Guarantee Period 1 3 5 6 7 8 9 10 | |Initial Premium ______ _______ _______ ________ _______ _______ ______ _______| |Total Premium _____________ | | | |------------------------------------------------------------------------------| |5. TYPE OF ANNUITY | |IRA Indicate contribution amount and appropriate tax year________________ | |__IRA Rollover __SEP IRA __SAR SEP IRA | |__403(B) TSA Transfer __401(a) Plan __Conduit IRA | |__Roth IRA If transfer, provide original conversion date______________ | |__Simple IRA Transfer Provide establishment date____________ | |__Other__________________________ | |------------------------------------------------------------------------------| |6. REPLACEMENT | |IS THE POLICY APPLIED FOR TO REPLACE OR CHANGE ANY EXISTING LIFE | |INSURANCE OR ANNUITY CONTRACT? __YES __NO | |______________________________________________________________________________| |Company Name Policy Number Cash Value | | | |------------------------------------------------------------------------------| |7. SPECIAL REMARKS | | | | | | | |------------------------------------------------------------------------------| |8. OWNER(S) ACKNOWLEDGEMENTS | |Please read the following statements carefully and sign on the back: | | | |BY SIGNING, I ACKNOWLEDGE RECEIPT OF THE PROSPECTUS. I AGREE THAT, TO | |THE BEST OF MY KNOWLEDGE AND BELIEF, ALL STATEMENTS AND ANSWERS ABOVE | |ARE COMPLETE AND TRUE AND MAY BE RELIED UPON IN DETERMINING WHETHER TO | |ISSUE THE CONTRACT. ONLY THE OWNER AND GOLDEN AMERICAN HAVE THE AUTHORITY | |TO MODIFY THIS DOCUMENT. | | | |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. | | | |I UNDERSTAND THAT ANY AMOUNT ALLOCATED TO A GUARANTEE PERIOD MAY BE SUBJECT | |TO A MARKET VALUE ADJUSTMENT, WHICH MAY CAUSE THE VALUES TO INCREASE OR | |DECREASE, PRIOR TO A SPECIFIED DATE OR DATES AS SPECIFIED IN THE CONTRACT. | |(CONTINUED ON BACK) | |------------------------------------------------------------------------------| GA-GIA-1070 107753 6/2000 |------------------------------------------------------------------------------| |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. | | | |The following states acknowledgement of a fraud warning statement. Please | |refer to the fraud warning statement for your state as indicated below. Check | |the appropriate box pertaining to your resident state, sign and date at the | |bottom of this section (if your state is not listed, simply sign and date at | |the bottom). | | | |__ARKANSAS, COLORADO, KENTUCKY, WASHINGTON DC. Any person who knowingly | |and with intent to defraud any insurance company or other person files an | |application containing any materialy false information, or conceals for the | |purpose of misleading information concerning any fact material thereto, | |commits a fraudulent insurance act, which is a crime. | | | |__MAINE. 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. | | | |__MINNESOTA. This policy/contract/certificate is not protected by the | | | |Minnesota Life and Health Insurance Guaranty Association or the | |Minnesota Insurance Guaranty Association. In the case of insolvency, | |payment of claims is not guaranteed. Only the assets of this insurer | |will be available to pay your claim. | | | |__NEW MEXICO. 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 civil fines and criminal penalties. | | | |__NEW JERSEY. Any person who includes any false or misleading information | |on an application for ani insurance policy is subject to criminal and | |civil penalties. | | | |__OHIO. Any person who submits an application or files a claim containing | |a false or deceptive statement, with intent to defraud or knowingly | |facilitating a fraud against an insurer, is guilty of insurance fraud. | | | |__PENNSYLVANIA. Any person who knowingly and with intent to defraud any | |insurance company or other person files an application containing | |any materialy 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. | | | |__VIRGINIA. Any person who, with 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. | | | |Signed at: City____________________ State____ Date ____/____/____ | |________________________ (_____)_____-_________ _________________________ | |Owner's Signature Telephone Number Joint Owner's Signature | | | |On receiving your written request, we will provide you with information | |regarding the benefits and provisions of the annuity contract for which | |you have applied. If you are not satisfied, you may cancel your policy by | |returning it within 10 days after the date you receive it along with a signed | |statement requesting a free look. Any premium paid for the returned policy | |will be refunded without interest. | | | |------------------------------------------------------------------------------| |9. AGENT'S REPORT: To the best of your knowledge, does the policy applied for | |involve replacement or modification of any existing life insurance or annuity | |contract? __Yes __No If yes, submit required replacement forms. | | | |Producer Contract Employee Contract | |Client's Account Number: __________________ | | | |______________________________________________________________________________| |Agent Signature Print Agent Name Social Security # Broker/Dealer/Branch| | | | | | | | | | | | | |------------------------------------------------------------------------------| GA-GIA-1070 107753 6/2000
