Golden American Life Insurance Company Deferred Variable Annuity Enrollment Form

Summary

This enrollment form is used by individuals to apply for a deferred variable annuity contract issued by Golden American Life Insurance Company and distributed by Directed Services, Inc. Applicants provide personal information, select annuity options, designate beneficiaries, and allocate their initial investment among various investment divisions. The form also allows for optional features such as dollar cost averaging and telephone reallocation authorization. The agreement outlines the key choices and authorizations required to establish and manage the annuity contract.

EX-4.F 11 0011.txt GROUP DEF. COMB. VAR. & FIXED ANNUITY ENROLLMENT FORM Exhibit 4(f) | | [ENROLLMENT FORM appears down the left margin] | | PW | -- | | A GOLDEN OPPORTUNITY FOR SELECT CLIENTS | | GoldenSelect/R/ Access One Enrollment Form | | | | | | | | | | | | | | | | | | | | | | | | | [GOLDENSELECT/R/ ACCESS ONE VARIABLE ANNUITY appears down left margin] | | | | | | | | | | | Issued by Golden American Life Insurance Company | Distributed by Directed Services, Inc., Member NASD | GA-EA-1064 ING VARIABLE ANNUITIES | 107026 | GOLDEN AMERICAN LIFE INSURANCE COMPANY DEFERRED VARIABLE ANNUITY PW ENROLLMENT FORM -- P.O. Box 2700, West Chester, PA ###-###-#### Phone ###-###-#### Express Mail: ING Variable Annuities 1475 Dunwoody Drive West Chester, PA 19380 =============================================================================== |1(A)| OWNER - ------ Name: SSN# or Tax ID: - ------------------------------------------------------------------------------- Permanent Address: City: State: Zip: - ------------------------------------------------------------------------------- Date of Birth: Phone: EMail Address: Male / / Female / / - ------------------------------------------------------------------------------- =============================================================================== |1(B)| JOINT OWNER(S) Relationship to Owner: - ------ ---------------------- Name: SSN# or Tax ID: - ------------------------------------------------------------------------------- Permanent Address: City: State: Zip: - ------------------------------------------------------------------------------- Date of Birth: Phone: EMail Address: Male / / Female / / - ------------------------------------------------------------------------------- =============================================================================== |2(A)| ANNUITANT (If other than owner) - ------ Name: SSN# or Tax ID: - ------------------------------------------------------------------------------- Permanent Address: City: State: Zip: - ------------------------------------------------------------------------------- Date of Birth: Phone: EMail Address: Male / / Female / / - ------------------------------------------------------------------------------- =============================================================================== |2(B)| CONTINGENT ANNUITANT (Optional) - ------ Name: SSN# or Tax ID: - ------------------------------------------------------------------------------- Permanent Address: City: State: Zip: - ------------------------------------------------------------------------------- Date of Birth: Phone: EMail Address: Male / / Female / / - ------------------------------------------------------------------------------- =============================================================================== | 3 | BENEFICIARY(S) - ----- Percentage Primary Name: Relationship to Owner: % --------------- ----------------- --------- Primary Name: Relationship to Owner: % --------------- ----------------- --------- Primary Name: Relationship to Owner: % --------------- ----------------- --------- Contingent Name: Relationship to Owner: % --------------- ----------------- --------- Contingent Name: Relationship to Owner: % --------------- ----------------- --------- =============================================================================== | 4 | - ----- PRODUCT DEATH BENEFIT OPTIONS (Select One) Standard Ratchet(1) 7% Solution(1) MAX 7(1) Access One / / / / / / / / - ------------------------------------------------------------------------------- (1) Not available for joint ownership 107026 GA-EA-1064 05/01/2000 =============================================================================== | 5 | INITIAL PREMIUM AND ALLOCATION INFORMATION PW - ----- -- A. INITIAL INVESTMENT 1) Initial Premium Paid: $________ (If initital premium is either an exchange or transfe, please indicate approximate premium.) Please make check payable to Golden American Life Insurance Company 2) Fill in percentages for your initial investment allocation(s) in Column (A) below B. DOLLAR COST AVERAGING (DCA) OPTIONAL 1) Amount to be transferred monthly $_________ (Max: 1/12of premium allocated to divisions below: 1/6 for 6 Month DCA) 2) Division or Allocation your transferred from: / /Limited Maturity Bond Division / /Liquid Asset Division / /1 YR Fixed / / 6 Month DCA 3) Please indicate the divisions you wish to transfer to by filling in percentage and dollar amounts in Column B below INVESTMENT ADVISER ACCOUNT DIVISION A)INITIAL INVESTMENT B)DCA - ------------------ ---------------- ------------------ --- A I M CAPITAL CAPITAL APPRECIATION $________ ________% ______% MANAGMENT, INC. A I M CAPITAL STRATEGIC EQUITY $________ ________% ______% MANAGMENT, INC. ALLIANCE CAPITAL CAPITAL GROWTH $________ ________% ______% MANAGMENT, INC. BARING INTERNATIONAL GLOBAL FIXED INCOME $________ ________% ______% INVESTMENT LIMITED BARING INTERNATIONAL HARD ASSETS $________ ________% ______% INVESTMENT LIMITED BARING INTERNATIONAL DEVELOPING WORLD $________ ________% ______% INVESTMENT LIMITED CAPITAL GUARDIAN SMALL CAP $________ ________% ______% TRUST COMPANY CAPITAL GUARDIAN MANAGED GLOBAL $________ ________% ______% TRUST COMPANY CAPITAL GUARDIAN LARGE CAP $________ ________% ______% TRUST COMPANY EAGLE ASSET VALUE EQUITY $________ ________% ______% MANAGEMENT, LLC ING INVESTMENT MANAGEMENT ING GLOBAL BRAND NAMES $________ ________% ______% ADVISORS B.V. ING INVESTMENT LIMITED MATURITY BOND $________ ________% ______% MANAGEMENT, LLC ING INVESTMENT LIQUID ASSET $________ ________% ______% MANAGEMENT, LLC JANUS CAPITAL GROWTH $________ ________% ______% CORPORATION JENNISON ASSOCIATES LLC PRUDENTIAL JENNISON $________ ________% ______% KAYNE ANDERSON RISING DIVIDENDS $________ ________% ______% INVESTMENT MANAGEMENT,LLC MFS INVESTMENT MID-CAP GROWTH $________ ________% ______% MANAGEMENT MFS INVESTMENT RESEARCH $________ ________% ______% MANAGEMENT MFS INVESTMENT TOTAL RETURN $________ ________% ______% MANAGEMENT PACIFIC INVESTMENT MANAGEMENT COMPANY (PIMCO) HIGH YIELD BOND $________ ________% ______% PACIFIC INVESTMENT MANAGEMENT COMPANY (PIMCO) StocksPLUS GROWTH $________ ________% ______% & INCOME PRUDENTIAL INVESTMENT CORPORATION REAL ESTATE $________ ________% ______% SALOMON BROTHERS ALL-CAP $________ ________% ______% ASSET MANAGEMENT, INC. SALOMON BROTHERS INVESTORS $________ ________% ______% ASSET MANAGEMENT, INC. T. ROWE PRICE EQUITY INCOME $________ ________% ______% ASSOCIATES INC. T. ROWE PRICE FULLY MANAGED $________ ________% ______% ASSOCIATES INC. FIXED ALLOCATIONS: / /1 YR / /3 YR / /5 YR / /7 YR / /10 YR (Not Available in all states) $________ ________% ______% TOTAL = $________ 100% 100% GA-EA-1064 107026 05/01/2000 =============================================================================== | 6 | TELEPHONE REALLOCATION AUTHORIZATION PW - ----- -- (Owner's initials to validate agent)_______ I authorize Golden American to act upon reallocation instructions given by electronic means or voice command from the agen that signs below and/or the following individuals:______________________, _______________________; upon furnishing his/her social security number or alternative identification. Neither Golden American nor any person authorized by Golden American will be responsible for any claim, loss, liability or expenses in connection with reallocation instructions received by electronic means or voice command from such person if Golden American or other such person acted on such electronic means or voice command in good faith in reliance upon this authorization. Golden American 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 that I notify Golden American in writing of a change in instructions. =============================================================================== | 7 | TAX-QUALIFIED PLANS (If you are funding a qualified plan, please - ----- specify type): / /IRA Indicate contribution amount and appropriate tax year ________________ / /IRA Rollover / /SEP/IRA / /SAR SEP IRA / /401(B) TSA Transfer / /401(a) Plan / /CONDUIT IRA / /Roth IRA If transfer, provide original conversion date ___________ / /Simple IRA Transfer Provide establishment date ____________ / / Other _____________ Employer Name_____________________________ =============================================================================== | 8 | REPLACEMENT - ---- Will the coverage applied for replace any existing annuity or life insurance coverage? / / Yes (If yes, please fill in below) / / No Company Name: Policy Number: Cash Value: --------------------- ---------- ---------- =============================================================================== | 9 | PLEASE READ THE FOLLOWING STATEMENTS 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 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 GOLDEN AMERICAN HAVE THE AUTHORITY TO MODIFY THIS APPLICATION. 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 THE CONTRACT'S CASH SURRENDER VALUE, 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. THE CONTRACT'S COVERAGE IS IN ACCORD WITH MY ANTICIPATED FINANCIAL OBJECTIVES. I UNDERSTAND THAT ANY AMOUNT ALLOCATED TO THE FIXED ACCOUNT MAY BE SUBJECT TO A MARKET VALUE ADJUSTMENT, WHICH MAY CAUSE THE VALUES TO INCREASE OR DECREAS, PRIOR TO A SPECIFIED DATE OR DATES AS SPECIFIED INTHE CONTRACT. MY SIGNATURE CERTIFIES, UNDER PENALTY OF PERJURY, THAT TEH 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 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 CERTIFICATION 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 Signed at (City, State) Date Owner) =============================================================================== |10| SPECIAL REMARKS - ---- =============================================================================== |11| 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 / / NO Client Account Number: _____________________ _______________________________________________________________________________ Agent Signature Print Agent Name Social Security # Broker/Dealer/Branch GA-EA-1064 107026 05/01/2000