Golden American Life Insurance Company Single Premium Deferred Annuity Enrollment Form

Summary

This enrollment form is used by individuals applying for a single premium deferred annuity with Golden American Life Insurance Company. The form collects information about the applicant, annuitant, beneficiaries, and the type of annuity selected. Applicants must certify the accuracy of their information, acknowledge receipt of the prospectus, and agree to the terms, including potential market value adjustments and investment risks. The form also includes fraud warnings and requires signatures from the applicant and, if applicable, the agent. Applicants have the right to cancel within 10 days of receiving the policy for a full refund.

EX-4.F 6 0006.txt SINGLE PREM. DEFERRED ANNUITY ENROLLMENT FORM EXHIBIT 4(f) GOLDEN AMERICAN LIFE INSURANCE COMPANY MODIFIED GUARANTEED ANNUITY PO BOX 2700 WEST CHESTER, PA ###-###-#### ENROLLMENT FORM PHONE: (800) 366-0066 Express Mail:ING Variable Annuities 1475 Dunwoody Drive West Chester, PA 19380 |-----------------------------------------------------------------------------| |1. POLICY INFORMATION | |GOLDENSELECT Guarantee Annuity | |Guarantee Period 1 3 5 6 7 8 9 10 | |Initial Premium ____ ____ ____ ____ ____ ____ ____ ____ | |Total Premium _____________ | |-----------------------------------------------------------------------------| |2. 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_________________________________________ | |-----------------------------------------------------------------------------| |3. POLICY OWNER JOINT OWNER | |(If different from annuitant) (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___________ | |-----------------------------------------------------------------------------| |4. ANNUITANT JOINT ANNUITANT (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___________ | |-----------------------------------------------------------------------------| |5. PRIMARY BENEFICIARY(IES) | |FULL NAME(S) RELATIONSHIP TO ANNUITANT SOCIAL SECURITY # % TO RECEIVE | |____________________________________________________________________________ | |____________________________________________________________________________ | |____________________________________________________________________________ | |(Add separate sheet signed by policyowner for additional/contingent | |beneficiary information.) | |-----------------------------------------------------------------------------| |6. REPLACEMENT | |IS THE POLICY APPLIED FOR TO REPLACE OR CHANGE ANY EXISTING LIFE | |INSURANCE OR ANNUITY CONTRACT? __ YES __ NO | |-----------------------------------------------------------------------------| |7. RATE LOCK - 1035(A) EXCHANGES / TRANSFER RATE LOCK YES _________% | |If Rate Lock is not selected, the rate will be determined when Golden | |American receives the funds. Estimated dollar amount $_________ | |-----------------------------------------------------------------------------| |8. SPECIAL REMARKS | | | | | |-----------------------------------------------------------------------------| |9. 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 IN THIS | |ENROLLMENT FORM ARE COMPLETE AND TRUE AND MAY BE RELIED UPON IN DETERMINING | |WHETHER TO ISSUE THE CERTIFICATE. ONLY THE OWNER AND GOLDEN AMERICAN HAVE | |THE AUTHORITY TO MODIFY THIS ENROLLMENT FORM. | | | |CERTIFICATES 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 CERTIFICATE.| | (CONTINUED ON BACK) | |-----------------------------------------------------------------------------| GA-EA-1070 5/25/2000 - ------------------------------------------------------------------------------| |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). | | | |__KENTUCKY. 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. | | | |__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. | | | |__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. | | | |__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. | | | |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. Any premium paid for the returned policy will be refunded | |without interest. | |-----------------------------------------------------------------------------| |10. 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-EA-1070 5/25/2000