GOLDEN AMERICAN LIFE INSURANCE COMPANY                               SMARTDESIGN
PO Box 2700 West Chester, PA 19380-2700
Phone: (800) 366-0066                  EQUITY INDEXED MODIFIED GUARANTEE ANNUITY
Express Mail: ING Variable Annuities                          CUSTOMER DATA FORM
1475 Dunwoody Drive West Chester, PA 19380
________________________________________________________________________________
1. OWNER                           JOINT OWNER(Not applicable if qualified plan)
Name___________________            Name________________________
Address________________            Address_____________________
City___State___ Zip____            City_____________ State_____ Zip_______
Male__ Female__ Date of Birth_/_/_ Male__ Female__ Date of Birth __/__/__
Social Security Number_____ Social Security Number_______
Phone Number__________ Phone Number ___________________________________
________________________________________________________________________________
2. ANNUITANT (If other than owner)
Name______________________________  Male__ Female__ Date of Birth ____/____/____
Address____________________________ Social Security Number__________________
City_________ State_____ Zip_______ Phone Number____________________________
________________________________________________________________________________
3. PRIMARY BENEFICIARY(IES)
Full Name(s)   Relationship to Owner     Social Security #      % to Receive
___________    _____________________     _________________      _____________
___________    _____________________     _________________      _____________
___________    _____________________     _________________      _____________
___________    _____________________     _________________      _____________
(Add separate sheet signed and dated by contract owner for additional/contingent
beneficiary information.)
________________________________________________________________________________
4. PREMIUM ALLOCATION
Divisions-Interest___% or $__ Term Indexed__% or $__ Annual Indexed__% or $____
Guarantee Period (select one): 5 Years 7 Years 10 Years Total Premium$_________
________________________________________________________________________________
5. TYPE OF ANNUITY
__IRA/ IRA Rollover - Indicate contribution amount and appropriate tax year:
_____/_____/____ $________________
__Roth IRA - If transfer, provide original conversion date and amount:
_____/_____/____ $________________
__Non-qualified SAR SEP IRA 403 (B) TSA Transfer SEP IRA Simple IRA Other ______
________________________________________________________________________________
6. REPLACEMENT
Do you currently have any existing annuity or life insurance policies or
coverage? __Yes (If yes, please continue below)__No

This  purchase  may involve  discontinuing  or  changing  an existing  policy or
contract.  If so,  a  replacement  is  occurring.  Financed  purchases  are also
considered replacements.

A  replacement  occurs  when a new  policy or  contract  is  purchased  and,  in
connection  with the  sale,  you  discontinue  making  premium  payments  on the
existing  policy or contract,  or an existing policy or contract is surrendered,
forfeited, assigned to the replacing insurer, or otherwise terminated or used in
a financed purchase.

A financed  purchase occurs when the purchase of a new life insurance  policy or
an annuity  contract  involves the use of funds  obtained by the  withdrawal  or
surrender  of or by  borrowing  some  or  all of the  policy  values,  including
accumulated dividends,  of an existing policy, to pay all or part of any premium
or payment due on the new policy. A financed purchase is a replacement.

You should  carefully  consider  whether a replacement is in your best interest.
You will pay  acquisition  costs and there may be surrender  costs deducted from
your policy or contract. You may be able to make changes to your existing policy
or contract to meet your insurance needs at less cost. A financed  purchase will
reduce the value of your existing policy and may reduce the amount paid upon the
death of the  insured.  We want you to  understand  the effects of  replacements
before you make your  purchase  decision  and ask that you answer the  following
questions.

1. Are you  considering  discontinuing  making premium  payments,  surrendering,
forfeiting,  assigning to the insurer,  or otherwise  terminating  your existing
policy or contract? __Yes __No

2. Are you considering  using funds from your existing  policies or contracts to
pay premiums due on the new policy or contract? __ Yes __No

If you  answered  "yes" to either of the above  questions,  please  complete the
"Important  Notice:  Replacement of Life  Insurance or Annuities,"  and return a
copy with this form, with any state replacement  forms, if applicable.

I  do  not   want   this   notice   read   aloud   to   me,   _________________.
Owner/Applicant(s)  must sign only if they do not want the  notice  read  aloud.
________________________________________________________________________________
(Continued on back)

GA-CDF-1101                                                    111173 10/12/2001

<PAGE>
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7.  SPECIAL  REMARKS

________________________________________________________________________________
8.  STATE  REQUIRED  NOTICES - Please  read the  following carefully to see if
any of the provisions below apply in your state.

Arkansas,  Colorado,  Kentucky,  Louisiana,  New Mexico, Ohio,  Pennsylvania and
Washington  DC:  "Any  person  who  knowingly  and with  intent to  defraud  any
insurance  company or any other person  files an  application  for  insurance or
statement of claim containing any materially false information, or conceals, for
the purpose of  misleading,  information  concerning  any material fact thereto,
commits a fraudulent  insurance act which is a crime and subjects such person to
criminal and civil penalties."

California: For your protection, California law requires the following to appear
on this form. "Any person who knowingly presents a false or fraudulent claim for
the  payment  of a loss is  guilty of a crime  and may be  subject  to fines and
confinement in a state prison."

California  Assembly Bill 2107 Disclosure:  The sale or liquidation of any asset
in order to buy  insurance,  either life insurance or an annuity  contract,  may
have tax consequences. Terminating any life insurance policy or annuity contract
may have early withdrawal penalties or other costs or penalties,  as well as tax
consequences.  You may wish to consult  independent  legal or  financial  advice
before the sale or liquidation of any asset,  stock,  bond, IRA,  certificate of
deposit, mutual fund, life insurance policy, annuity contract or other asset.

Florida: "Any person who knowingly and with the intent to injure, defraud, or
deceive any insurer files a statement of claim or any application containing any
false, incomplete or misleading information is guilty of a felony of the third
degree."

Maine, Tennessee: "It is a crime to knowingly provide false, incomplete
or misleading information to an insurance company for the purpose of defrauding
the company. Penalties may include imprisonment, fines or denial of insurance
benefits."

Minnesota: This contract is not protected by the Minnesota Life and
Health Insurance Guaranty Association or the Minnesota Guarantee Association. In
the case of insolvency, payment of claim is not guaranteed. Only the assets of
this insurer will be available to pay your claim.

New Jersey: "Any person who includes any false or misleading information on an
application for an insurance policy is subject to criminal and civil penalties."

Virginia: A person who, with the intent to defraud or knowing that he is
facilitating a fraud against an insurer, submits an application or files a claim
containing a false or deceptive statement may have violated the state law."
________________________________________________________________________________
9. OWNER(S) ACKNOWLEDGEMENTS - Please read the following statements carefully
and sign.

I agree that, to the best of my knowledge and belief, all statements and answers
above are complete and true and may be relied upon in determining whether to
issue the contract. Only the owner and Golden American have the authority to
modify this document.

Annuity 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.

I understand that I am applying for an equity indexed annuity. I understand that
while its values may be  affected  by an external  index,  the annuity  does not
participate in any stock or equity investments.

I understand that any amount allocated to the annuity applied for may be subject
to a market value adjustment, which may cause the values to increase or decrease
in dollar amount if withdrawn or surrendered  prior to a specified date or dates
as stated in the  contract.

My  signature   certifies,   under   penalty  of  perjury,   that  the  taxpayer
identification  number  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
withholding  resulting 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  Internal  Revenue
Service does not require my consent to any provision of this document other than
the certifications required to avoid backup withholding.

Signed  at:  (City)__________   (State)___________  on  (Date)_____/_____/_____.
Owner's Signature__Joint Owner's Signature__(if applicable) Annuitant Signature_
________________________________________________________________________________
10. AGENT'S REPORT: Do you have any reason to believe that the applicant has any
existing life policies or annuity contracts? __Yes __No (If yes, submit required
replacement  forms.)
Client's  Account Number:  __________________

Commission  Options (select one - please verify with your Broker/Dealer that
the option you select is available)
A___ B___ C___ D___ E___
_______________ _________________________ ________________ _____________________
Agent Signature Agent Name (please print) Social Security# Broker/Dealer/Branch
___________  ______________  __________________________
Agent Phone  E-mail address  License# (FL  Agents  Only)
________________________________________________________________________________
GA-CDF-1101                                                   111173 10/12/2001