Exhibit 1.A.(10)(a)(i)
| Southland Life Insurance Company |
Investment Feature Selection Form
Survivor Dimensions
Market Dimensions
Section A - Initial Premium Allocation
Initial Premium Allocation.Please allocate your Initial Premium to the Guaranteed Interest Division and/or among the investment options of the Separate Account. 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
Alger American | Fidelity Variable Insurance Products Fund II | INVESCO Variable Investment Fund (VIF) | |||||
____ % | Growth Portfolio | ____ % | VIP II Asset Manager Portfolio | ____ % | VIF Equity Income Fund | ||
____ % | Leveraged AllCap Portfolio | ____ % | VIP II Contrafund Portfolio | ____ % | VIF Utilities Fund | ||
____ % | MidCap Growth Portfolio | ____ % | VIP II Index 500 Portfolio | ||||
____ % | Small Capitalization Portfolio | ____ % | VIP II Investment Grade Bond Portfolio | Janus Aspen Series | |||
____ % | Aggressive Growth Portfolio | ||||||
Fidelity Variable Insurance Products Fund | GCG Trust | ____ % | Balanced Portfolio | ||||
____ % | VIP Equity-Income Portfolio | ____ % | Liquid Assets Portfolio | ____ % | Growth Portfolio | ||
____ % | VIP Growth Portfolio | ____ % | Mid-Cap Growth Portfolio | ____ % | International Growth Portfolio | ||
____ % | VIP High Income Portfolio | ____ % | Research Portfolio | ____ % | Worldwide Growth Portfolio | ||
____ % | VIP Overseas Portfolio | ____ % | Total Return Portfolio | ||||
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 authorization/revocation instructions. We further authorize ING Security Life to record telephone conversations with any person utilizing telephone privileges on the policy listed in Section 2. I/We understand that ING Security Life reserves the right to discontinue the telephone privilege at any time.
| Funds Effective Date:_____________________ |
21-420
Section C - Automatic Rebalancing Option
[ ] Initiate Automatic Rebalancing (complete below)
[ ] Change Automatic Rebalancing (complete below)
Automatic Rebalancing Allocation
Alger American | Fidelity Variable Insurance Products Fund II | INVESCO Variable Investment Fund (VIF) | |||||
____ % | Growth Portfolio | ____ % | VIP II Asset Manager Portfolio | ____ % | VIF Equity Income Fund | ||
____ % | Leveraged AllCap Portfolio | ____ % | VIP II Contrafund Portfolio | ____ % | VIF Utilities Fund | ||
____ % | MidCap Growth Portfolio | ____ % | VIP II Index 500 Portfolio | ||||
____ % | Small Capitalization Portfolio | ____ % | VIP II Investment Grade Bond Portfolio | Janus Aspen Series | |||
____ % | Aggressive Growth Portfolio | ||||||
Fidelity Variable Insurance Products Fund | GCG Trust | ____ % | Balanced Portfolio | ||||
____ % | VIP Equity-Income Portfolio | ____ % | Liquid Assets Portfolio | ____ % | Growth Portfolio | ||
____ % | VIP Growth Portfolio | ____ % | Mid-Cap Growth Portfolio | ____ % | International Growth Portfolio | ||
____ % | VIP High Income Portfolio | ____ % | Research Portfolio | ____ % | Worldwide Growth Portfolio | ||
____ % | VIP Overseas Portfolio | ____ % | Total Return Portfolio | ||||
____%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) [ ] Fidelity Investment Money Market Division [ ] Neuberger Berman Limited Maturity Bond Investment Option
into: the Separate Account Investment Option(s) selected below.
Dollar Cost Averaging Allocation
Alger American | GCG Trust | |||
$____or____% | Growth Portfolio | $____or____% | Liquid Assets Portfolio | |
$____or____% | Leveraged AllCap Portfolio | $____or____% | Mid-Cap Growth Portfolio | |
$____or____% | MidCap Growth Portfolio | $____or____% | Research Portfolio | |
$____or____% | Small Capitalization Portfolio | $____or____% | Total Return Portfolio | |
Fidelity Variable Insurance Products Fund (VIP) | INVESCO Variable Investment Fund (VIF) | |||
$____or____% | VIP Equity-Income Portfolio | $____or____% | VIF Equity Income Fund | |
$____or____% | VIP Growth Portfolio | $____or____% | VIF Utilities Fund | |
$____or____% | VIP High Income Portfolio | |||
$____or____% | VIP Overseas Portfolio | Janus Aspen Series | ||
$____or____% | Aggressive Growth Portfolio | |||
Fidelity Variable Insurance Products Fund II (VIP II) | $____or____% | Balanced Portfolio | ||
$____or____% | VIP II Asset Manager Portfolio | $____or____% | Growth Portfolio | |
$____or____% | VIP II Contrafund Portfolio | $____or____% | International Growth Portfolio | |
$____or____% | VIP II Index 500 Portfolio | $____or____% | Worldwide Growth Portfolio | |
$____or____% | VIP II Investment Grade Bond Portfolio | |||
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 $_________________
Section E - Premium Allocation Change Request
Alger American | Fidelity Variable Insurance Products Fund II | INVESCO Variable Investment Fund (VIF) | |||||
____ % | Growth Portfolio | ____ % | VIP II Asset Manager Portfolio | ____ % | VIF Equity Income Fund | ||
____ % | Leveraged AllCap Portfolio | ____ % | VIP II Contrafund Portfolio | ____ % | VIF Utilities Fund | ||
____ % | MidCap Growth Portfolio | ____ % | VIP II Index 500 Portfolio | ||||
____ % | Small Capitalization Portfolio | ____ % | VIP II Investment Grade Bond Portfolio | Janus Aspen Series | |||
____ % | Aggressive Growth Portfolio | ||||||
Fidelity Variable Insurance Products Fund | GCG Trust | ____ % | Balanced Portfolio | ||||
____ % | VIP Equity-Income Portfolio | ____ % | Liquid Assets Portfolio | ____ % | Growth Portfolio | ||
____ % | VIP Growth Portfolio | ____ % | Mid-Cap Growth Portfolio | ____ % | International Growth Portfolio | ||
____ % | VIP High Income Portfolio | ____ % | Research Portfolio | ____ % | Worldwide Growth Portfolio | ||
____ % | VIP Overseas Portfolio | ____ % | Total Return Portfolio | ||||
_____%Guaranteed Interest Division
Section F - Signatures
I/We acknowledge that we have read and understand:
- the terms and conditions listed in the instructions to this form, the Prospectus and the Policy for each of the options or changes requested.
- I/we can cancel or change any elections requested in Sections 5 and 7 above by sending written notice to the Customer Service Center at least 7 days before the next transfer date.
- 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:_________________________