EX-2 6 exhibit26e3.htm EXHIBIT 26(E)(3) exhibit26e3.htm - Generated by SEC Publisher for SEC Filing

Exhibit 26(e)(3):  M Financial Fund Allocation of Premiuim Payments Form (Form No. 139192 04/30/2012)

    Life
M FINANCIAL    
FUND ALLOCATION OF PREMIUM PAYMENTS  
Security Life of Denver Insurance Company, Denver, CO    
A member of the ING family of companies    ING Logo
ING Customer Service Center: PO Box 5065, Minot, ND 58702-5065 Your future. Made easier.®
Product Policy Number/List Bill Number

 

A. PREMIUM ALLOCATION

Initial or Future Premium Allocations: Current investment allocations will remain the same. See Section D for Investment Transfer Request.

Premium Allocation: Please allocate your 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%. For all premium allocation rules, please refer to the prospectuses.

CA Residents age 60 and older: Unless you tell us otherwise, during the 30 day free look period we allocate your initial net premium to the money market investment option. At the end of the free look period, we will automatically reallocate your policy value among the various investment options according to the allocation instructions on this form. For more information, please see your policy and prospectus, ask your representative or contact the ING Customer Service Center.

_______% Guaranteed Interest Division 1
American Funds Insurance Series®
_______% American Growth - Class 2 (AFR)
_______% American Growth-Income - Class 2 (AFG)
_______% American International - Class 2 (AFI)
BlackRock Variable Series Funds, Inc.
_______% BlackRock Global Allocation V.I. - Class III (BGA)
Fidelity® Variable Insurance Products
_______% Fidelity® VIP Contrafund® - Service Class (FCP)
_______% Fidelity® VIP Equity-Income - Service Class (FSE)
ING Balanced Portfolio, Inc.
_______% ING Balanced - Class I (VBI)
ING Intermediate Bond Portfolio
_______% ING Intermediate Bond - Class I (VPB)
ING Investors Trust
_______% ING Artio Foreign - Class I (JBF)
_______% ING BlackRock Health Sciences Opportunities - Class I (EHS)
_______% ING BlackRock Large Cap Growth - Class I (GFG)
_______% ING Clarion Global Real Estate - Class S (IGT)
_______% ING DFA Global Allocation - Class I (DGA)
_______% ING DFA World Equity - Class I (IFO)
_______% ING FMRSM Diversified Mid Cap - Class I (FDI)
_______% ING Franklin Templeton Founding Strategy - Class I (IFT)
_______% ING Global Resources - Class I (IHA)
_______% ING Invesco Van Kampen Growth and Income - Class S (GRD)
_______% ING JPMorgan Emerging Markets Equity - Class I (JEI)
_______% ING JPMorgan Small Cap Core Equity - Class I (IJS)
_______% ING Large Cap Growth - Class I (EOP)
_______% ING Limited Maturity Bond - Class S (ILM)
_______% ING Liquid Assets - Class I (ILP) 2
_______% ING Liquid Assets - Class S (ILA) 3
_______% ING Marsico Growth - Class I (IMG)
_______% ING MFS Total Return - Class I (IMT)
_______% ING MFS Utilities - Class S (MUP)
_______% ING PIMCO Total Return Bond - Class I (IPC)
_______% ING Pioneer Fund - Class I (PFS)
_______% ING Pioneer Mid Cap Value - Class I (PMV)
_______% ING Retirement Growth - Class I (RGI)
_______% ING Retirement Moderate Growth - Class I (RMG)
_______% ING Retirement Moderate - Class I (RMP)
_______% ING T. Rowe Price Capital Appreciation - Class I (GFM)
_______% ING T. Rowe Price Equity Income - Class I (TEI)
_______% ING T. Rowe Price International Stock - Class I (MIO)
_______% ING U.S. Stock Index - Class I (ISP)
ING Partners, Inc.
_______% ING Baron Growth - Class I (BSC)
_______% ING Columbia Small Cap Value II - Class I (CSI)
_______% ING Global Bond - Class S (OSI)
_______% ING Invesco Van Kampen Comstock - Class I (VKC)
_______% ING Invesco Van Kampen Equity and Income - Class I (UTA)
_______% ING JPMorgan Mid Cap Value - Class I (MCV)
_______% ING Oppenheimer Global - Class I (GGP)
_______% ING Pioneer High Yield - Class I (PHP)
_______% ING T. Rowe Price Diversified Mid Cap Growth - Class I (DMI)
_______% ING Templeton Foreign Equity - Class I (TPI)
_______% ING UBS U.S. Large Cap Equity - Class I (ULI)
ING Variable Funds
_______% ING Growth and Income - Class I (GIP)
ING Variable Portfolios, Inc.
_______% ING Index Plus LargeCap - Class I (IPL)
_______% ING Index Plus MidCap - Class I (IPM)
_______% ING Index Plus SmallCap - Class I (IPS)
_______% ING International Index - Class S (III)
_______% ING Russell™ Large Cap Growth Index - Class I (IRC)
_______% ING Russell™ Large Cap Index - Class I (IRI)
_______% ING Russell™ Large Cap Value Index - Class I (IRV)
_______% ING Russell™ Mid Cap Growth Index - Class I (IRM)
_______% ING Russell™ Small Cap Index - Class I (IRS)
_______% ING Small Company - Class S (ISS)
_______% ING U.S. Bond Index - Class I (ILB)
ING Variable Products Trust
_______% ING SmallCap Opportunities - Class I (NIG)
M Funds
_______% M Business Opportunity Value (BOV)
_______% M Capital Appreciation (MFC)
_______% M International Equity (MBI)
_______% M Large Cap Growth (MTC)
Neuberger Berman Advisers Management Trust
_______% Neuberger Berman AMT Socially Responsive® - Class I (NSR)

Designated Deduction Option: You may designate one investment option from which you want charges taken. If no investment option is designated or there is insufficient value in the option, charges will be deducted in proportion to the value invested in each investment option on the date of the charge.

Investment Option Name                                                                                                    

Page 1 of 6 (Note: Signature required on last page.) Order #139192 04/30/2012

 

 

Product Policy Number/List Bill Number
B. AUTOMATIC REBALANCING OPTION (Automatically rebalances the Accumulation Value periodically to maintain a specified percentage
allocation among the selected Sub-Accounts or Guaranteed Interest Division.)
Complete allocation below to:    c Initiate Automatic Rebalancing c Change Automatic Rebalancing
 
_______% Guaranteed Interest Division 1  

 

American Funds Insurance Series®
_______% American Growth - Class 2 (AFR)
_______% American Growth-Income - Class 2 (AFG)
_______% American International - Class 2 (AFI)
BlackRock Variable Series Funds, Inc.
_______% BlackRock Global Allocation V.I. - Class III (BGA)
Fidelity® Variable Insurance Products
_______% Fidelity® VIP Contrafund® - Service Class (FCP)
_______% Fidelity® VIP Equity-Income - Service Class (FSE)
ING Balanced Portfolio, Inc.
_______% ING Balanced - Class I (VBI)
ING Intermediate Bond Portfolio
_______% ING Intermediate Bond - Class I (VPB)
ING Investors Trust
_______% ING Artio Foreign - Class I (JBF)
_______% ING BlackRock Health Sciences Opportunities - Class I (EHS)
_______% ING BlackRock Large Cap Growth - Class I (GFG)
_______% ING Clarion Global Real Estate - Class S (IGT)
_______% ING DFA Global Allocation - Class I (DGA)
_______% ING DFA World Equity - Class I (IFO)
_______% ING FMRSM Diversified Mid Cap - Class I (FDI)
_______% ING Franklin Templeton Founding Strategy - Class I (IFT)
_______% ING Global Resources - Class I (IHA)
_______% ING Invesco Van Kampen Growth and Income - Class S (GRD)
_______% ING JPMorgan Emerging Markets Equity - Class I (JEI)
_______% ING JPMorgan Small Cap Core Equity - Class I (IJS)
_______% ING Large Cap Growth - Class I (EOP)
_______% ING Limited Maturity Bond - Class S (ILM)
_______% ING Liquid Assets - Class I (ILP) 2
_______% ING Liquid Assets - Class S (ILA) 3
_______% ING Marsico Growth - Class I (IMG)
_______% ING MFS Total Return - Class I (IMT)
_______% ING MFS Utilities - Class S (MUP)
_______% ING PIMCO Total Return Bond - Class I (IPC)
_______% ING Pioneer Fund - Class I (PFS)
_______% ING Pioneer Mid Cap Value - Class I (PMV)
_______% ING Retirement Growth - Class I (RGI)
_______% ING Retirement Moderate Growth - Class I (RMG)
_______% ING Retirement Moderate - Class I (RMP)
_______% ING T. Rowe Price Capital Appreciation - Class I (GFM)
_______% ING T. Rowe Price Equity Income - Class I (TEI)
_______% ING T. Rowe Price International Stock - Class I (MIO)
_______% ING U.S. Stock Index - Class I (ISP)
ING Partners, Inc.
_______% ING Baron Growth - Class I (BSC)
_______% ING Columbia Small Cap Value II - Class I (CSI)
_______% ING Global Bond - Class S (OSI)
_______% ING Invesco Van Kampen Comstock - Class I (VKC)
_______% ING Invesco Van Kampen Equity and Income - Class I (UTA)
_______% ING JPMorgan Mid Cap Value - Class I (MCV)
_______% ING Oppenheimer Global - Class I (GGP)
_______% ING Pioneer High Yield - Class I (PHP)
_______% ING T. Rowe Price Diversified Mid Cap Growth - Class I (DMI)
_______% ING Templeton Foreign Equity - Class I (TPI)
_______% ING UBS U.S. Large Cap Equity - Class I (ULI)
ING Variable Funds
_______% ING Growth and Income - Class I (GIP)
ING Variable Portfolios, Inc.
_______% ING Index Plus LargeCap - Class I (IPL)
_______% ING Index Plus MidCap - Class I (IPM)
_______% ING Index Plus SmallCap - Class I (IPS)
_______% ING International Index - Class S (III)
_______% ING Russell™ Large Cap Growth Index - Class I (IRC)
_______% ING Russell™ Large Cap Index - Class I (IRI)
_______% ING Russell™ Large Cap Value Index - Class I (IRV)
_______% ING Russell™ Mid Cap Growth Index - Class I (IRM)
_______% ING Russell™ Small Cap Index - Class I (IRS)
_______% ING Small Company - Class S (ISS)
_______% ING U.S. Bond Index - Class I (ILB)
ING Variable Products Trust
_______% ING SmallCap Opportunities - Class I (NIG)
M Funds
_______% M Business Opportunity Value (BOV)
_______% M Capital Appreciation (MFC)
_______% M International Equity (MBI)
_______% M Large Cap Growth (MTC)
Neuberger Berman Advisers Management Trust
_______% Neuberger Berman AMT Socially Responsive® - Class I (NSR)

Frequency and Date of Automatic Rebalancing (If no options are marked, frequency will be quarterly and/or date will be last valuation of calendar period.)
Frequency: c Monthly c Quarterly c Semi-annually c Annually  
Date: c Policy Processing Date: Date on which processing will occur based on frequency selected beginning  
  c Last Valuation Date of Calendar Period  
  c Specific Date of each Period beginning  
 
Please Terminate terminate an Existing my Portfolio Automatic Rebalancing Rebalancing Service immediately. Service (initial here)  
  Page 2 of 6 (Note: Signature required on last page.) Order #139192 04/30/2012

 

 

Product Policy Number/List Bill Number
C. DOLLAR COST AVERAGING OPTION (Systematic method of investing, where securities are purchased at regular intervals so the cost of the
securities is averaged over time.)  
The policyowner must have at least $10,000 invested in the source fund in order to initiate Dollar Cost Averaging.
Please transfer $__________________ or __________________% from:  c ING Liquid Assets Portfolio      c ING Limited Maturity Bond Portfolio

 

American Funds Insurance Series®
$__________________ or __________________% American Growth - Class 2 (AFR)  
$__________________ or __________________% American Growth-Income - Class 2 (AFG)  
$__________________ or __________________% American International - Class 2 (AFI)  
  BlackRock Variable Series Funds, Inc.  
$__________________ or __________________% BlackRock Global Allocation V.I. - Class III (BGA)  
  Fidelity® Variable Insurance Products  
$__________________ or __________________% Fidelity® VIP Contrafund® - Service Class (FCP)  
$__________________ or __________________% Fidelity® VIP Equity-Income - Service Class (FSE)  
  ING Balanced Portfolio, Inc.  
$__________________ or __________________% ING Balanced - Class I (VBI)  
ING Intermediate Bond Portfolio
$__________________ or __________________% ING Intermediate Bond - Class I (VPB)  
  ING Investors Trust  
$__________________ or __________________% ING Artio Foreign - Class I (JBF)  
$__________________ or __________________% ING BlackRock Health Sciences Opportunities - Class I (EHS)  
$__________________ or __________________% ING BlackRock Large Cap Growth - Class I (GFG)  
$__________________ or __________________% ING Clarion Global Real Estate - Class S (IGT)  
$__________________ or __________________% ING DFA Global Allocation - Class I (DGA)  
$__________________ or __________________% ING DFA World Equity - Class I (IFO)  
$__________________ or __________________% ING FMRSM Diversified Mid Cap - Class I (FDI)  
$__________________ or __________________% ING Franklin Templeton Founding Strategy - Class I (IFT)  
$__________________ or __________________% ING Global Resources - Class I (IHA)  
$__________________ or __________________% ING Invesco Van Kampen Growth and Income - Class S (GRD)  
$__________________ or __________________% ING JPMorgan Emerging Markets Equity - Class I (JEI)  
$__________________ or __________________% ING JPMorgan Small Cap Core Equity - Class I (IJS)  
$__________________ or __________________% ING Large Cap Growth - Class I (EOP)  
$__________________ or __________________% ING Limited Maturity Bond - Class S (ILM)  
$__________________ or __________________% ING Liquid Assets - Class I (ILP) 2  
$__________________ or __________________% ING Liquid Assets - Class S (ILA) 3  
$__________________ or __________________% ING Marsico Growth - Class I (IMG)  
$__________________ or __________________% ING MFS Total Return - Class I (IMT)  
$__________________ or __________________% ING MFS Utilities - Class S (MUP)  
$__________________ or __________________% ING PIMCO Total Return Bond - Class I (IPC)  
$__________________ or __________________% ING Pioneer Fund - Class I (PFS)  
$__________________ or __________________% ING Pioneer Mid Cap Value - Class I (PMV)  
$__________________ or __________________% ING Retirement Growth - Class I (RGI)  
$__________________ or __________________% ING Retirement Moderate Growth - Class I (RMG)  
$__________________ or __________________% ING Retirement Moderate - Class I (RMP)  
$__________________ or __________________% ING T. Rowe Price Capital Appreciation - Class I (GFM)  
$__________________ or __________________% ING T. Rowe Price Equity Income - Class I (TEI)  
$__________________ or __________________% ING T. Rowe Price International Stock - Class I (MIO)  
(DOLLAR COST AVERAGING OPTION - Continued on next page)  
Page 3 of 6 (Note: Signature required on last page.) Order #139192 04/30/2012

 

 

Product   Policy Number/List Bill Number  
C. DOLLAR COST AVERAGING OPTION (Continued)  
$__________________ or __________________% ING U.S. Stock Index - Class I (ISP)  
    ING Partners, Inc.  
$__________________ or __________________% ING Baron Growth - Class I (BSC)  
$__________________ or __________________% ING Columbia Small Cap Value II - Class I (CSI)  
$__________________ or __________________% ING Global Bond - Class S (OSI)  
$__________________ or __________________% ING Invesco Van Kampen Comstock - Class I (VKC)  
$__________________ or __________________% ING Invesco Van Kampen Equity and Income - Class I (UTA)  
$__________________ or __________________% ING JPMorgan Mid Cap Value - Class I (MCV)  
$__________________ or __________________% ING Oppenheimer Global - Class I (GGP)  
$__________________ or __________________% ING Pioneer High Yield - Class I (PHP)  
$__________________ or __________________% ING T. Rowe Price Diversified Mid Cap Growth - Class I (DMI)  
$__________________ or __________________% ING Templeton Foreign Equity - Class I (TPI)  
$__________________ or __________________% ING UBS U.S. Large Cap Equity - Class I (ULI)  
    ING Variable Funds  
$__________________ or __________________% ING Growth and Income - Class I (GIP)  
    ING Variable Portfolios, Inc.  
$__________________ or __________________% ING Index Plus LargeCap - Class I (IPL)  
$__________________ or __________________% ING Index Plus MidCap - Class I (IPM)  
$__________________ or __________________% ING Index Plus SmallCap - Class I (IPS)  
$__________________ or __________________% ING International Index - Class S (III)  
$__________________ or __________________% ING Russell™ Large Cap Growth Index - Class I (IRC)  
$__________________ or __________________% ING Russell™ Large Cap Index - Class I (IRI)  
$__________________ or __________________% ING Russell™ Large Cap Value Index - Class I (IRV)  
$__________________ or __________________% ING Russell™ Mid Cap Growth Index - Class I (IRM)  
$__________________ or __________________% ING Russell™ Small Cap Index - Class I (IRS)  
$__________________ or __________________% ING Small Company - Class S (ISS)  
$__________________ or __________________% ING U.S. Bond Index - Class I (ILB)  
    ING Variable Products Trust  
$__________________ or __________________% ING SmallCap Opportunities - Class I (NIG)  
    M Funds  
$__________________ or __________________% M Business Opportunity Value (BOV)  
$__________________ or __________________% M Capital Appreciation (MFC)  
$__________________ or __________________% M International Equity (MBI)  
$__________________ or __________________% M Large Cap Growth (MTC)  
    Neuberger Berman Advisers Management Trust  
$__________________ or __________________% Neuberger Berman AMT Socially Responsive® - Class I (NSR)  
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: c Monthly c Quarterly c Semi-annually c Annually  
Date: c Policy Processing Date: Date on which processing will occur based on frequency selected beginning  
  c Specific Date of each Period beginning  
Terminate an Existing Dollar Cost Averaging Service  
c Terminate Dollar Cost Averaging on    
c Terminate Dollar Cost Averaging when investment option from which money is being transferred reaches $  
c Please terminate my Dollar Cost Averaging Service immediately. (initial here)  
  Page 4 of 6 (Note: Signature required on last page.) Order #139192 04/30/2012

 

 

Product Policy Number/List Bill Number
 
D. INVESTMENT TRANSFER REQUEST    
c Current Investment Only   c Current and Future Investments (If no box is checked, it is assumed Current Investment Only.)
If no information is provided in the “Transfer From” column, we will assume that all amounts currently allocated to the investment options, excluding amounts
allocated to the Guaranteed Interest Division, will be reallocated as requested in the “Transfer To” column.  
Transfer From Investment Option Transfer To
$__________________ or _________% Guaranteed Interest Division (GID) 1 $__________________ or _________%
  American Funds Insurance Series®  
$__________________ or _________% American Growth - Class 2 (AFR) $__________________ or _________%
$__________________ or _________% American Growth-Income - Class 2 (AFG) $__________________ or _________%
$__________________ or _________% American International - Class 2 (AFI) $__________________ or _________%
  BlackRock Variable Series Funds, Inc.  
$__________________ or _________% BlackRock Global Allocation V.I. Fund - Class III (BGA) $__________________ or _________%
  Fidelity® Variable Insurance Products  
$__________________ or _________% Fidelity® VIP Contrafund® - Service Class (FCP) $__________________ or _________%
$__________________ or _________% Fidelity® VIP Equity-Income - Service Class (FSE) $__________________ or _________%
$__________________ or _________% Fidelity® VIP Investment Grade Bond - Initial Class (FIG) 4 N/A
  ING Balanced Portfolio, Inc.  
$__________________ or _________% ING Balanced - Class I (VBI) $__________________ or _________%
  ING Intermediate Bond Portfolio  
$__________________ or _________% ING Intermediate Bond - Class I (VPB) $__________________ or _________%
  ING Investors Trust  
$__________________ or _________% ING Artio Foreign - Class I (JBF) $__________________ or _________%
$__________________ or _________% ING BlackRock Health Sciences Opportunities - Class I (EHS) $__________________ or _________%
$__________________ or _________% ING BlackRock Large Cap Growth - Class I (GFG) $__________________ or _________%
$__________________ or _________% ING Clarion Global Real Estate - Class S (IGT) $__________________ or _________%
$__________________ or _________% ING DFA Global Allocation - Class I (DGA) $__________________ or _________%
$__________________ or _________% ING DFA World Equity - Class I (IFO) $__________________ or _________%
$__________________ or _________% ING FMRSM Diversified Mid Cap - Class I (FDI) $__________________ or _________%
$__________________ or _________% ING Franklin Templeton Founding Strategy - Class I (IFT) $__________________ or _________%
$__________________ or _________% ING Global Resources - Class I (IHA) $__________________ or _________%
$__________________ or _________% ING Invesco Van Kampen Growth and Income - Class S (GRD) $__________________ or _________%
$__________________ or _________% ING JPMorgan Emerging Markets Equity - Class I (JEI) $__________________ or _________%
$__________________ or _________% ING JPMorgan Small Cap Core Equity - Class I (IJS) $__________________ or _________%
$__________________ or _________% ING Large Cap Growth - Class I (EOP) $__________________ or _________%
$__________________ or _________% ING Large Cap Value - Class I (PEP) 4 N/A
$__________________ or _________% ING Limited Maturity Bond - Class S (ILM) $__________________ or _________%
$__________________ or _________% ING Liquid Assets - Class I (ILP) 2 $__________________ or _________%
$__________________ or _________% ING Liquid Assets - Class S (ILA) 3 $__________________ or _________%
$__________________ or _________% ING Marsico Growth - Class I (IMG) $__________________ or _________%
$__________________ or _________% ING MFS Total Return - Class I (IMT) $__________________ or _________%
$__________________ or _________% ING MFS Utilities - Class S (MUP) $__________________ or _________%
$__________________ or _________% ING PIMCO Total Return Bond - Class I (IPC) $__________________ or _________%
$__________________ or _________% ING Pioneer Fund - Class I (PFS) $__________________ or _________%
$__________________ or _________% ING Pioneer Mid Cap Value - Class I (PMV) $__________________ or _________%
$__________________ or _________% ING Retirement Growth - Class I (RGI) $__________________ or _________%
$__________________ or _________% ING Retirement Moderate Growth - Class I (RMG) $__________________ or _________%
$__________________ or _________% ING Retirement Moderate - Class I (RMP) $__________________ or _________%
$__________________ or _________% ING T. Rowe Price Capital Appreciation - Class I (GFM) $__________________ or _________%
$__________________ or _________% ING T. Rowe Price Equity Income - Class I (TEI) $__________________ or _________%
$__________________ or _________% ING T. Rowe Price International Stock - Class I (MIO) $__________________ or _________%
$__________________ or _________% ING U.S. Stock Index - Class I (ISP) $__________________ or _________%
  ING Partners, Inc.  
$__________________ or _________% ING American Century Small-Mid Cap Value - Class I (SCV) 4 N/A
$__________________ or _________% ING Baron Growth - Class I (BSC) $__________________ or _________%
$__________________ or _________% ING Columbia Small Cap Value II - Class I (CSI) $__________________ or _________%
$__________________ or _________% ING Global Bond - Class S (OSI) $__________________ or _________%
$__________________ or _________% ING Invesco Van Kampen Comstock - Class I (VKC) $__________________ or _________%
$__________________ or _________% ING Invesco Van Kampen Equity and Income - Class I (UTA) $__________________ or _________%
$__________________ or _________% ING JPMorgan Mid Cap Value - Class I (MCV) $__________________ or _________%
$__________________ or _________% ING Oppenheimer Global - Class I (GGP) $__________________ or _________%
(INVESTMENT TRANSFER REQUEST - Continued on next page)  
  Page 5 of 6 (Note: Signature required on last page.) Order #139192 04/30/2012

 

 

D.     

INVESTMENT TRANSFER REQUEST (Continued)

Transfer From Investment Option Transfer To
$__________________ or _________% ING PIMCO Total Return - Class I (PTR) 5 N/A
$__________________ or _________% ING Pioneer High Yield - Class I (PHP) $__________________ or _________%
$__________________ or _________% ING T. Rowe Price Diversified Mid Cap Growth - Class I (DMI) $__________________ or _________%
$__________________ or _________% ING Templeton Foreign Equity - Class I (TPI) $__________________ or _________%
$__________________ or _________% ING UBS U.S. Large Cap Equity - Class I (ULI) $__________________ or _________%
  ING Strategic Allocation Portfolio  
$__________________ or _________% ING Strategic Allocation Conservative - Class I (SAI) 4 N/A
$__________________ or _________% ING Strategic Allocation Growth - Class I (SAG) 4 N/A
$__________________ or _________% ING Strategic Allocation Moderate - Class I (SAB) 4 N/A
  ING Variable Funds  
$__________________ or _________% ING Growth and Income - Class I (GIP) $__________________ or _________%
  ING Variable Portfolios, Inc.  
$__________________ or _________% ING Index Plus LargeCap - Class I (IPL) $__________________ or _________%
$__________________ or _________% ING Index Plus MidCap - Class I (IPM) $__________________ or _________%
$__________________ or _________% ING Index Plus SmallCap - Class I (IPS) $__________________ or _________%
$__________________ or _________% ING International Index - Class S (III) $__________________ or _________%
$__________________ or _________% ING Russell™ Large Cap Growth Index - Class I (IRC) $__________________ or _________%
$__________________ or _________% ING Russell™ Large Cap Index - Class I (IRI) $__________________ or _________%
$__________________ or _________% ING Russell™ Large Cap Value Index - Class I (IRV) $__________________ or _________%
$__________________ or _________% ING Russell™ Mid Cap Growth Index - Class I (IRM) $__________________ or _________%
$__________________ or _________% ING Russell™ Small Cap Index - Class I (IRS) $__________________ or _________%
$__________________ or _________% ING Small Company - Class S (ISS) $__________________ or _________%
$__________________ or _________% ING U.S. Bond Index - Class I (ILB) $__________________ or _________%
  ING Variable Products Trust  
$__________________ or _________% ING MidCap Opportunities - Class I (PMO) 4 N/A
$__________________ or _________% ING SmallCap Opportunities - Class I (NIG) $__________________ or _________%
  Invesco Variable Insurance Funds  
$__________________ or _________% Invesco V.I. Core Equity Fund - Series I (ACE) 4 N/A
  MFunds  
$__________________ or _________% M Business Opportunity Value (BOV) $__________________ or _________%
$__________________ or _________% M Capital Appreciation (MFC) $__________________ or _________%
$__________________ or _________% M International Equity (MBI) $__________________ or _________%
$__________________ or _________% M Large Cap Growth (MTC) $__________________ or _________%
  Neuberger Berman Advisers Management Trust  
$__________________ or _________% Neuberger Berman AMT Socially Responsive® - Class I (NSR) $__________________ or _________%
  Van Eck  
$__________________ or _________% Van Eck VIP Global Hard Assets Fund (WHA) 6 N/A

 

Endnotes
1 Transfers to and from the Guaranteed Interest Division have specific time and amount limitations. Please refer to your policy or prospectus for additional information.
2 Not available with Asset Accumulator, Asset Portfolio Manager, Corporate Benefits, ING Corporate VUL, ING SVUL-CV, ING VUL-CV, ING VUL-DB, ING VUL-ECV or Strategic Investor.
3 Not available with Estate Designer, FirstLine, FirstLine II, Strategic Advantage, Strategic Advantage II or Variable Survivorship.
4 Not available with ING Corporate VUL, ING SVUL-CV, ING VUL-CV, ING VUL-DB or ING VUL-ECV.
5 Not available with ING SVUL-CV, ING VUL-DB or ING VUL-ECV.
6 Not available with Corporate Benefits, ING Corporate VUL, ING SVUL-CV, ING VUL-CV, ING VUL-DB or ING VUL-ECV.

E. SIGNATURES (If Owner is a Corporation, Trust, or Partnership, signature and title of Officer is required.)

I/We acknowledge that we have read and understand: 1. the terms and conditions listed in the instructions to this form and that we have received and read the Prospectus for this policy. 2. I/we can cancel or change any elections requested in Sections B and C above by sending written notice to the ING Customer Service Center before the next transfer date. 3. that Dollar Cost Averaging and Automatic Rebalancing will begin on the date specified only if the ING Customer Service Center has received and accepted this signed form before the date specified.

Owner(s) Name        
 Owner's Signature Date
Registered Representative Name        
 Registered Representative Signature   Date    
 Spouse Signature (if applicable)
Insured(s) Name        
 Policy Number/List Bill Number 7 Daytime Phone (              )
7 For corporate owned/sponsored plans, please attach list of applicable policies.      
  Page 6 of 6   Order #139192 05/01/2011