Exhibit 1.A.(10)(a)(i)
 | | Security Life of Denver Insurance Company
Variable Life Custtomer Service Center
P.O. Box 173888 · Denver, CO 80217-3888
1-800-848-6362 |
Investment Feature Selection Form
Security Life of Denver Insurance Company
Asset Portfolio Manager
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
| Aim | | The GCG Trust | Neuberger Berman |
| ________ % | V.I. Capital Appreciation Fund | | ________ % | Liquid Asset Portfolio | ________ % | AMT Growth Portfolio |
| ________ % | V.I. Government Securities Fund | | | ________ % | AMT Limited Maturity Bond Portfolio |
| | | INVESCO Variable Investment Fund (VIF) | ________ % | AMT Partners Portfolio |
| Alger American | | ________ % | VIF-Equity Income Fund | |
| ________ % | Growth Portfolio | | ________ % | VIF-High Yield Fund | Van Eck |
| ________ % | Leveraged AllCap Portfolio | | ________ % | VIF-Small Company Growth Fund | ________ % | Worldwide Bond Fund |
| ________ % | MidCap Growth Portfolio | | ________ % | VIF-Total Return Fund | ________ % | Worldwide Emerging Markets Fund |
| ________ % | Small Capitalization Portfolio | | ________ % | VIF-Utilities Fund | ________ % | Worldwide Hard Assets Fund |
| | | | | ________ % | Worldwide Real Estate Fund |
| Fidelity Variable Insurance Products Fund (VIP) | | Janus Aspen Series | | |
| ________ % | VIP Growth Portfolio (Service Class) | | ________ % | Aggressive Growth Portfolio | | |
| ________ % | VIP Overseas Portfolio (Service Class) | | ________ % | Growth Portfolio | | |
| | | ________ % | International Growth Portfolio | | |
| Fidelity Variable Insurance Products Fund II (VIP II) | | ________ % | Worldwide Growth Portfolio | | |
| ________ % | VIP II Asset Manager Portfolio | | | | | |
| ________ % | VIP II Index 500 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.
V-153-00
Section C - Automatic Rebalancing Option
[ ] Initiate Automatic Rebalancing (complete below)
[ ] Change Automatic Rebalancing (complete below)
Automatic Rebalancing Allocation
| Aim | | The GCG Trust | Neuberger Berman |
| ________ % | V.I. Capital Appreciation Fund | | ________ % | Liquid Asset Portfolio | ________ % | AMT Growth Portfolio |
| ________ % | V.I. Government Securities Fund | | | ________ % | AMT Limited Maturity Bond Portfolio |
| | | INVESCO Variable Investment Fund (VIF) | ________ % | AMT Partners Portfolio |
| Alger American | | ________ % | VIF-Equity Income Fund | |
| ________ % | Growth Portfolio | | ________ % | VIF-High Yield Fund | Van Eck |
| ________ % | Leveraged AllCap Portfolio | | ________ % | VIF-Small Company Growth Fund | ________ % | Worldwide Bond Fund |
| ________ % | MidCap Growth Portfolio | | ________ % | VIF-Total Return Fund | ________ % | Worldwide Emerging Markets Fund |
| ________ % | Small Capitalization Portfolio | | ________ % | VIF-Utilities Fund | ________ % | Worldwide Hard Assets Fund |
| | | | | ________ % | Worldwide Real Estate Fund |
| Fidelity Variable Insurance Products Fund (VIP) | | Janus Aspen Series | | |
| ________ % | VIP Growth Portfolio (Service Class) | | ________ % | Aggressive Growth Portfolio | | |
| ________ % | VIP Overseas Portfolio (Service Class) | | ________ % | Growth Portfolio | | |
| | | ________ % | International Growth Portfolio | | |
| Fidelity Variable Insurance Products Fund II (VIP II) | | ________ % | Worldwide Growth Portfolio | | |
| ________ % | VIP II Asset Manager Portfolio | | | | | |
| ________ % | VIP II Index 500 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) | [ ] | The GCG Trust Liquid Asset Portfolio | [ ] | Neuberger Berman Limited Maturity Bond Investment Option |
into: the Separate Account Investment Option(s) selected below.
Dollar Cost Averaging Allocation
| AIM | | | Janus Aspen Series |
| $________or________% | V.I. Capital Appreciation Fund | | $________or________% | Aggressive Growth Portfolio |
| $________or________% | V.I. Government Securities Fund | | $________or________% | Balanced Portfolio |
| Alger American | | $________or________% | Growth Portfolio |
| $________or________% | Growth Portfolio | | $________or________% | International Growth Portfolio |
| $________or________% | Leveraged AllCap Portfolio | | $________or________% | Worldwide Growth Portfolio |
| $________or________% | MidCap Growth Portfolio | | | Neuberger Berman |
| $________or________% | Small Capitalization Portfolio | | $________or________% | AMT Growth Portfolio |
| Fidelity Variable Insurance Products Fund (VIP) | | $________or________% | AMT Limited Maturity Bond Portfolio |
| $________or________% | VIP Growth Portfolio (Service Class) | | $________or________% | AMT Partners Portfolio |
| $________or________% | VIP Overseas Portfolio (Service Class) | | | Van Eck |
| Fidelity Variable Insurance Products Fund II (VIP II) | | $________or________% | Worldwide Bond Fund |
| $________or________% | VIP II Asset Manager Portfolio | | $________or________% | Worldwide Emerging Markets Fund |
| $________or________% | VIP II Index 500 Portfolio | | $________or________% | Worldwide Hard Assets Fund |
| The GCG Trust | | $________or________% | Worldwide Real Estate Fund |
| $________or________% | Liquid Asset Portfolio | | | |
| INVESCO Variable Investment Fund (VIF) | | | |
| $________or________% | VIF Equity Income Fund | | | |
| $________or________% | VIF-High Yield Fund | | | |
| $________or________% | VIF-Small Company Growth Fund | | | |
| $________or________% | VIF-Total Return Fund | | | |
| $________or________% | VIF Utilities Fund | | | |
____% Guaranteed Interest Division
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
| Aim | | The GCG Trust | Neuberger Berman |
| ________ % | V.I. Capital Appreciation Fund | | ________ % | Liquid Asset Portfolio | ________ % | AMT Growth Portfolio |
| ________ % | V.I. Government Securities Fund | | | ________ % | AMT Limited Maturity Bond Portfolio |
| | | INVESCO Variable Investment Fund (VIF) | ________ % | AMT Partners Portfolio |
| Alger American | | ________ % | VIF-Equity Income Fund | |
| ________ % | Growth Portfolio | | ________ % | VIF-High Yield Fund | Van Eck |
| ________ % | Leveraged AllCap Portfolio | | ________ % | VIF-Small Company Growth Fund | ________ % | Worldwide Bond Fund |
| ________ % | MidCap Growth Portfolio | | ________ % | VIF-Total Return Fund | ________ % | Worldwide Emerging Markets Fund |
| ________ % | Small Capitalization Portfolio | | ________ % | VIF-Utilities Fund | ________ % | Worldwide Hard Assets Fund |
| | | | | ________ % | Worldwide Real Estate Fund |
| Fidelity Variable Insurance Products Fund (VIP) | | Janus Aspen Series | | |
| ________ % | VIP Growth Portfolio (Service Class) | | ________ % | Aggressive Growth Portfolio | | |
| ________ % | VIP Overseas Portfolio (Service Class) | | ________ % | Growth Portfolio | | |
| | | ________ % | International Growth Portfolio | | |
| Fidelity Variable Insurance Products Fund II (VIP II) | | ________ % | Worldwide Growth Portfolio | | |
| ________ % | VIP II Asset Manager Portfolio | | | | | |
| ________ % | VIP II Index 500 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:_________________________
