EX-1.A10AII 2 v_166-01.htm INV FEATURE SELECTION FORM V-166-00

EXHIBIT 1.A(10)(a)(ii)

[LOGO OF SECURITY LIFE]

Security Life of Denver Insurance Company
Variable Life Customer Service Center
P.O. Box 173888 · Denver, CO 80217-3888
1-800-848-6362 · ing-securitylife.com

[ ]Asset Portfolio Manager

Supplement to Flexible Premium Variable Life Insurance Application
Investment Feature Selection Form

Section A – Initial Premium Allocation

Initial Premium Allocation. Please allocate your Initial Premium among the investment options of the Separate Account and/or to the Guaranteed Interest Division. Please use whole number percentages for each division/option elected. You must allocate at least 1% of your premium allocation to each division/option in which you elect to invest. The total must equal 100%.

_______% GUARANTEED INTEREST DIVISION

SEPARATE ACCOUNT INVESTMENT OPTIONS
     
AIM    
_____%   V.I. Capital Appreciation Fund
_____%   V.I. Government Securities Fund
     
Alger American
_____%   Growth Portfolio
_____%   Leveraged AllCap Portfolio
_____%   MidCap Growth Portfolio
_____%   Small Capitalization Portfolio
     
Fidelity Variable Insurance Products Fund (VIP)
_____%   Growth Portfolio (Service Class)
_____%   Overseas Portfolio (Service Class)
     
Fidelity Variable Insurance Products Fund II (VIPII)
_____%   Asset Manager Portfolio (Service Class)
_____%   Index 500 Portfolio
     
The GCG Trust
_____%   Fully Managed Portfolio
_____%   Liquid Asset Portfolio
_____%   MidCap Growth Portfolio
     
INVESCO Variable Investment Fund (VIF)
_____%   VIF-Equity Income Fund
_____%   VIF-High Yield Fund
_____%   VIF-Small Company Growth Fund
_____%   VIF-Total Return Fund
_____%   VIF-Utilities Fund
     
Janus Aspen Series (Service Shares)
_____%   Aggressive Growth Portfolio
_____%   Growth Portfolio
_____%   International Growth Portfolio
_____%   Worldwide Growth Portfolio
     
Neuberger Berman
_____%   AMT Growth Portfolio
_____%   AMT Limited Maturity Bond Portfolio
_____%   AMT Partners Portfolio
     
Pilgrim Variable Products Trust
_____%   Growth Opportunities Portfolio
_____%   MagnaCap Portfolio
_____%   MidCap Opportunities Portfolio
_____%   SmallCap Opportunities Portfolio
     
Putnam Variable Trust
_____%   Growth & Income Fund Class IB Shares
_____%   New Opportunities Fund Class IB Shares
_____%   SmallCap Value Fund Class IB Shares
_____%   Voyager Fund Class IB Shares
     
Van Eck    
_____%   Worldwide Bond Fund
_____%   Worldwide Emerging Markets Fund
_____%   Worldwide Hard Assets Fund
_____%   Worldwide Real Estate Fund

Section B – Telephone Privilege Authorization

[ ] Telephone Privilege Authorization: I/We authorize Security Life of Denver Insurance Company to accept telephone instructions from the Owners/ Registered Representative of the policy listed above:
  [ ]   Owners Only
  [ ]   Owner and Registered Representative
   
[ ] Revocation of Telephone Privilege Authorization: I/We revoke all telephone privilege authorization in place on the policy listed above for the following persons:
  [ ]   Owners and Registered Representative
  [ ]   Registered Representative Only
 

By signing this form, I/we agree to hold harmless and indemnify ING Security Life for any losses arising from such authorzation/revocation instructions. We futher authorize ING Security Life to record telephone conversation with any person utilizing telephone privileges on the policy listed in Section 2. I/We understand that ING Security Life reserves the right to discontinued the telephone privilege at any time.

Note: Signature required on back page. 


V-166-00								Rev. 5/1/01

Section C – Automatic Rebalancing Option

[ ] Initiate Automatic Rebalancing (complete below)
[ ] Change Automatic Rebalancing (complete below)

 

Automatic Rebalancing Allocation
     
AIM    
_____%   V.I. Capital Appreciation Fund
_____%   V.I. Government Securities Fund
     
Alger American
_____%   Growth Portfolio
_____%   Leveraged AllCap Portfolio
_____%   MidCap Growth Portfolio
_____%   Small Capitalization Portfolio
     
Fidelity Variable Insurance Products Fund (VIP)
_____%   Growth Portfolio
_____%   Overseas Portfolio
     
Fidelity Variable Insurance Products Fund II (VIPII)
_____%   Asset Manager Portfolio
_____%   Index 500 Portfolio
     
The GCG Trust
_____%   Fully Managed Portfolio
_____%   Liquid Asset Portfolio
_____%   MidCap Growth Portfolio
     
INVESCO Variable Investment Fund (VIF)
_____%   VIF-Equity Income Fund
_____%   VIF-High Yield Fund
_____%   VIF-Small Company Growth Fund
_____%   VIF-Total Return Fund
_____%   VIF-Utilities Fund
     
Janus Aspen Series (Service Shares)
_____%   Aggressive Growth Portfolio
_____%   Growth Portfolio
_____%   International Growth Portfolio
_____%   Worldwide Growth Portfolio
     
Neuberger Berman
_____%   AMT Growth Portfolio
_____%   AMT Limited Maturity Bond Portfolio
_____%   AMT Partners Portfolio
     
Pilgrim Variable Products Trust
_____%   Growth Opportunities Portfolio
_____%   MagnaCap Portfolio
_____%   MidCap Opportunities Portfolio
_____%   SmallCap Opportunities Portfolio
     
Putnam Variable Trust
_____%   Growth & Income Fund Class IB Shares
_____%   New Opportunities Fund Class IB Shares
_____%   SmallCap Value Fund Class IB Shares
_____%   Voyager Fund Class IB Shares
     
Van Eck    
_____%   Worldwide Bond Fund
_____%   Worldwide Emerging Markets Fund
_____%   Worldwide Hard Assets Fund
_____%   Worldwide Real Estate Fund

___________ % Guaranteed Interest Division

Frequency and Date of Automatic Rebalancing: (If no options are marked, frequency will be quarterly and/or date will be last valuation date of calendar period.)

Frequency:

[ ]  Monthly       [ ]   Quarterly     [ ]   Semi-annually       [ ]   Annually

Date:

[ ]  Policy Processing Date - Date on which processing will occur based on frequency selected beginning _______________________ (Month/Date)
[ ]  Last Valuation Date of Calendar Period
[ ]  Specific Date each Period beginning________________________
                                                                            (Specify Date)

Section D – Dollar Cost Averaging Option

[ ] Initiate Dollar Cost Averaging (complete below) [ ] Change Dollar Cost Averaging (complete below)

Please transfer $ _________ or _________ % from:

(check one only)  [ ] The GCG Trust Liquid Asset Portfolio   [ ]   Neuberger Bermen Limited Maturity Bond Investment Option

      Intro: the Separate Account Investment Options(s) selected below. 

 

Dollar Cost Averaging Option

AIM
$________or________%   V.I. Capital Appreciation Fund
$________or________%   V.I. Government Securities Fund
     
Alger American    
$________or________%   Growth Portfolio
$________or________%   Leveraged AllCap Portfolio
$________or________%   MidCap Growth Portfolio
$________or________%   Small Capitalization Portfolio
     
Fidelity Variable Insurance Products Fund (VIP)
$________or________%   Growth Portfolio (Service Class)
$________or________%   Overseas Portfolio (Service Class)
     
Fidelity Variable Insurance Products Fund II (VIPII)
$________or________%   Asset Manager Portfolio (Service Class)
$________or________%   Index 500 Portfolio
     
The GCG Trust
$________or________%   Fully Managed Portfolio
$________or________%   Liquid Asset Portfolio
$________or________%   MidCap Growth Portfolio
     
INVESCO Variable Investment Fund (VIF)
$________or________%   VIF-Equity Income Funds
$________or________%   VIF-High Yield Fund
$________or________%   VIF-Small Company Growth Fund
$________or________%   VIF-Total Return Fund
$________or________%   VIF-Utilities Fund
     
Janus Aspen Series (Service Shares)
$________or________%   Aggressive Growth Portfolio
$________or________%   Growth Portfolio
$________or________%   International Growth Portfolio
$________or________%   Worldwide Growth Portfolio
     
Neuberger Berman
$________or________%   AMT Growth Portfolio
$________or________%   AMT Limited Maturity Bond Portfolio
$________or________%   AMT Partners Portfolio
     
Pilgrim Variable Products Trust
$________or________%   Growth Opportunities Portfolio
$________or________%   MagnaCap Portfolio
$________or________%   MidCap Opportunities Portfolio
$________or________%   SmallCap Opportunities Portfolio
     
Putnam Variable Trust
$________or________%   Growth & Income Fund Class IB Shares
$________or________%   New Opportunities Fund Class IB Shares
$________or________%   SmallCap Value Fund Class IB Shares
$________or________%   Voyager Fund Class IB Shares
     
Van Eck
$________or________%   Worldwide Bond Fund
$________or________%   Worldwide Emerging Markets Fund
$________or________%   Worldwide Hard Assets Fund
$________or________%   Worldwide Real Estate Fund

Frequency and Date of Dollar Cost Averaging: (If no options are marked, frequency will be monthly and/or date will be policy processing date.)

Frequency:

[ ]  Monthly       [ ]   Quarterly     [ ]   Semi-annually       [ ]   Annually

Date:

[ ]  Policy Processing Date - Date on which processing will occur based on frequency selected beginning ____________________________ (Month/Date)
[ ]   Specific Date each Period beginning ____________________________(Specify Date)

Terminate:

[ ]  Terminate Dollar Cost Averaging on (date) ____________________________
[ ]  Terminate Dollar Cost Averaging when investment option from which money is being transferred reaches
$ ______________


V-166-00								Rev. 5/1/01

Section E – Premium Allocation Change Request

AIM    
_____%   V.I. Capital Appreciation Fund
_____%   V.I. Government Securities Fund
     
Alger American
_____%   Growth Portfolio
_____%   Leveraged AllCap Portfolio
_____%   MidCap Growth Portfolio
_____%   Small Capitalization Portfolio
     
Fidelity Variable Insurance Products Fund (VIP)
_____%   Growth Portfolio (Service Class)
_____%   Overseas Portfolio (Service Class)
     
Fidelity Variable Insurance Products Fund II (VIPII)
_____%   Asset Manager Portfolio (Service Class)
_____%   Index 500 Portfolio
     
The GCG Trust
_____%   Fully Managed Portfolio
_____%   Liquid Asset Portfolio
_____%   MidCap Growth Portfolio
     
INVESCO Variable Investment Fund (VIF)
_____%   VIF-Equity Income Fund
_____%   VIF-High Yield Fund
_____%   VIF-Small Company Growth Fund
_____%   VIF-Total Return Fund
_____%   VIF-Utilities Fund
     
Janus Aspen Series (Service Shares)
_____%   Aggressive Growth Portfolio
_____%   Growth Portfolio
_____%   International Growth Portfolio
_____%   Worldwide Growth Portfolio
     
Neuberger Berman
_____%   AMT Growth Portfolio
_____%   AMT Limited Maturity Bond Portfolio
_____%   AMT Partners Portfolio
     
Pilgrim Variable Products Trust
_____%   Growth Opportunities Portfolio
_____%   Magna Cap Portfolio
_____%   MidCap Opportunities Portfolio
_____%   SmallCap Opportunities Portfolio
     
Putnam Variable Trust
_____%   Growth & Income Fund Class IB Shares
_____%   New Opportunities Fund Class IB Shares
_____%   SmallCap Value Fund Class IB Shares
_____%   Voyager Fund Class IB Shares
     
Van Eck    
_____%   Worldwide Bond Fund
_____%   Worldwide Emerging Markets Fund
_____%   Worldwide Hard Assets Fund
_____%   Worldwide Real Estate Fund

___________% Guaranteed Interest Division

Section F – Signatures

I/We acknowledge that we have read and understand:
1. the terms and conditions listed in the instructions to this form, the Prospectus and the Policy for each of the options or changes requested.
2. I/we can cancel or change any elections requested in Sections C and D above by sending written notice to the Customer Service Center at least 7 days before the next transfer date.
3. that dollar cost averaging and automatic rebalancing will begin on the date specified only if ING Security Life has received this signed form at least 7 days before the date specified.

Signature of Owner(s):

______________________________________________________________________________   Date________________________________________

______________________________________________________________________________   Date________________________________________

______________________________________________________________________________   Date________________________________________

Daytime Phone Number: __________________________________