Document:

RELIASTAR                                     FLEXIBLE PREMIUM
LIFE INSURANCE COMPANY OF NEW YORK            DEFERRED COMBINATION VARIABLE
                                              AND FIXED ANNUITY ENROLLMENT FORM

RELIASTAR LIFE INSURANCE COMPANY OF NEW YORK IS A STOCK
  COMPANY DOMICILED IN NEW YORK

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1.   OWNER(S)
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Name                     Male      Female    Soc. Sec. # or Tax ID.#
                         / /        / /
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Permanent Address        Phone (   )

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City                     State     Zip       Date of Birth

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2.   ANNUITANT (IF OTHER THAN OWNER)
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Name                     Male      Female    Soc. Sec. # or Tax ID.#
                         / /        / /
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Permanent Address        Phone (   )

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City                     State     Zip       Date of Birth  Relation
                                                            to Owner
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     CONTINGENT ANNUITANT (OPTIONAL)
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Name                               Address                  Relation
                                                            to Owner
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3.   PRIMARY BENEFICIARY(IES)      (IF MORE THAN ONE - INDICATE %)
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Name(s)                                                     Relation
                                                            to Owner
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   CONTINGENT BENEFICIARY(IES)     Name                     Relation
                                                            to Owner
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4.   PLAN
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     / / DVA PLUS
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5.   DEATH BENEFIT OPTIONS
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     / / Annual Ratchet           / / Standard
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6.   INITIAL PREMIUM AND ALLOCATION INFORMATION
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     (A)  INITIAL PREMIUM PAID $__________ Make check payable to reliastar
          life insurance company of New York.
          Fill in percentages for premium allocation below (see INITIAL)

     (B)  CHARGE DEDUCTION DIVISION: Optional. Please check box to elect.
              / /

<Table>
<Caption>
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     ACCOUNT DIVISION                  INVESTMENT ADVISER                 (A) INITIAL
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<S>                                <C>                                        <C>
CAPITAL APPRECIATION               A I M CAPITAL MANAGEMENT,INC.              %
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STRATEGIC EQUITY                   A I M CAPITAL MANAGEMENT,INC.              %
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CAPITAL GROWTH                     ALLIANCE CAPITAL MANAGEMENT,LP             %
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DEVELOPING WORLD                   BARING INTERNATIONAL INVESTMENT LIMITED    %
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HARD ASSETS                        BARING INTERNATIONAL INVESTMENT LIMITED    %
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LARGE CAP VALUE                    CAPITAL GUARDIAN TRUST COMPANY             %
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MANAGED GLOBAL                     CAPITAL GUARDIAN TRUST COMPANY             %
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SMALL CAP                          CAPITAL GUARDIAN TRUST COMPANY             %
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VALUE EQUITY                       EAGLE ASSET MANAGEMENT,INC.                %
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DIVERSIFIED MID-CAP                FIDELITY MANAGEMENT &RESEARCH COMPANY      %
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ASSET ALLOCATION GROWTH            FIDELITY MANAGEMENT & RESEARCH COMPANY     %
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INTERNET TOLLKEEPER                GOLDMAN SACHS ASSET MANAGEMENT             %
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PILGRIM VP GROWTH OPPORTUNITIES    ING PILGRIM INVESTMENTS,LLC                %
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PILGRIM VP MAGNACAP                ING PILGRIM INVESTMENTS,LLC                %
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PILGRIM VP SMALLCAP OPPORTUNITIES  ING PILGRIM INVESTMENTS,LLC                %
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PILGRIM WORLDWIDE GROWTH           ING PILGRIM INVESTMENTS,LLC                %
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GALAXY VIP ASSET ALLOCATION        FLEET INVESTMENT ADVISOR,INC.              %
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GALAXY VIP EQUITY                  FLEET INVESTMENT ADVISOR,INC.              %
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GALAXY VIP GROWTH & INCOME         FLEET INVESTMENT ADVISOR,INC.              %
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GALAXY VIP HIGH QUALITY BOND       FLEET INVESTMENT ADVISOR,INC.              %
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GALAXY VIP SMALL COMPANY GROWTH    FLEET INVESTMENT ADVISOR,INC.              %
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LIMITED MATURITY BOND              ING INVESTMENT MANAGEMENT,LLC              %
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LIQUID ASSET                       ING INVESTMENT MANAGEMENT,LLC              %
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GROWTH                             JANUS CAPITAL CORPORATION                  %
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GROWTH AND INCOME                  JANUS CAPITAL CORPORATION                  %
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SPECIAL SITUATIONS                 JANUS CAPITAL CORPORATION                  %
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PRUDENTIAL JENNISON                JENNISON ASSOCIATES LLC                    %
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SP JENNISON INTERNATIONAL GROWTH   JENNISON ASSOCIATES LLC                    %
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RISING DIVIDENDS                   KAYNE ANDERSON RUDNIK INVESTMENT
                                     MANAGEMENT,LLC                           %
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MID-CAP GROWTH                     MASSACHUSETTS FINANCIAL SERVICES COMPANY   %
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RESEARCH                           MASSACHUSETTS FINANCIAL SERVICES COMPANY   %
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TOTAL RETURN                       MASSACHUSETTS FINANCIAL SERVICES COMPANY   %
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CORE BOND                          PACIFIC INVESTMENT MANAGEMENT COMPANY      %
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PIMCO HIGH YIELD BOND              PACIFIC INVESTMENT MANAGEMENT COMPANY      %
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PIMCO STOCKSPLUS GROWTH & INCOME   PACIFIC INVESTMENT MANAGEMENT COMPANY      %
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PROFUND VP BULL                    PROFUND ADVISORS,LLC                       %
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PROFUND VP SMALL CAP               PROFUND ADVISORS,LLC                       %
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PROFUND VP EUROPE 30               PROFUND ADVISORS,LLC                       %
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REAL ESTATE                        PRUDENTIAL INVESTMENT CORPORATION          %
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ALL CAP                            SALOMON BROTHERS ASSET MANAGEMENT INC.     %
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INVESTORS                          SALOMON BROTHERS ASSET MANAGEMENT INC.     %
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EQUITY INCOME                      T.ROWE PRICE ASSOCIATES,INC.               %
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FULLY MANAGED                      T.ROWE PRICE ASSOCIATES,INC.               %
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FIXED ALLOCATIONS:                 o 1 YR  o 3 YR  o 5 YR  o 7 YR o 10 YR     %
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                                   TOTAL                                    100%
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</Table>

                 RELIASTAR LIFE INSURANCE COMPANY OF NEW YORK,
                    VARIABLE PRODUCT CUSTOMER SERVICE CENTER
                   1475 Dunwoody Drive West Chester, PA 19380
                                 1-800-963-9539

FG-EA-1000-08/97 (PE)                                                08/24/2001
                                                                         000000

<PAGE>

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7. OPTIONAL SYSTEMATIC PARTIAL WITHDRAWALS
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If you want to receive Systematic Partial Withdrawals, your request must be
received in writing. For the appropriate form, please call our Customer
Service Center: 1-800-963-9539.
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8. TAX-QUALIFIED PLANS If you are funding a qualified plan, please specify
   type:
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     / / IRA    / / IRA Rollover    / / SEP/IRA    / /Other _______________
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9. REPLACEMENT
Will the coverage applied for replace any existing annuity or life
insurance policies on the annuitant's life?
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     / / Yes (If yes, please complete following.)       / / No
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Company Name                 Policy Number                      Face Amount

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10. READ THE FOLLOWING STATEMENTS CAREFULLY AND SIGN BELOW:
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     o    BY SIGNING BELOW, I ACKNOWLEDGE RECEIPT OF THE PROSPECTUS. I
          UNDERSTAND THAT THIS CONTRACT'S CASH SURRENDER VALUE, 1) WHEN BASED ON
          THE INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT DIVISION, MAY INCREASE
          OR DECREASE ON ANY DAY AND THAT NO MINIMUM VALUE IS GUARANTEED, AND 2)
          WHEN, BASED ON THE FIXED ACCOUNT, MAY BE SUBJECT TO A MARKET VALUE
          ADJUSTMENT, THE OPERATION OF WHICH MAY CAUSE THE VALUES TO INCREASE OR
          DECREASE. THIS CONTRACT IS IN ACCORD WITH MY ANTICIPATED FINANCIAL
          NEEDS.

     o    I AGREE THAT, TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL STATEMENTS
          AND ANSWERS IN THIS APPLICATION ARE COMPLETE AND TRUE AND MAY BE
          RELIED UPON IN DETERMINING WHETHER TO ISSUE THE CONTRACT. MY ANSWERS
          WILL FORM A PART OF ANY CONTRACT TO BE ISSUED, AND ONLY THE OWNER AND
          RELIASTAR HAVE THE AUTHORITY TO MODIFY THIS APPLICATION.

     o    CONTRACTS AND POLICIES AND UNDERLYING SERIES SHARES OR SECURITIES
          WHICH FUND 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. ALSO, THEY ARE SUBJECT TO MARKET
          FLUCTUATION, INVESTMENT RISK AND POSSIBLE LOSS OF PRINCIPAL INVESTED.

-------------------------------             ------------------------------------
Signature of Owner                          Signed at (City, State) Date

-------------------------------             ------------------------------------
Signature of Joint Owner (if applicable)    Signed at (City, State) Date

-------------------------------             ------------------------------------
Signature of Annuitant                      Signed at (City, State) Date
   (if other than Owner)

Client Account No. (if applicable)_____________________
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FOR AGENT USE ONLY

DO YOU HAVE REASON TO BELIEVE THAT THE COVERAGE APPLIED FOR WILL REPLACE ANY
EXISTING ANNUITY OR LIFE INSURANCE ON THE ANNUITANT'S LIFE?

     / / Yes     / / No
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------------------------------    ------------------------------
Agent Signature                   Print Agent Name & No.

------------------------------    ---------------------------------
Social Security No.               Broker/Dealer/Branch

Amendment to Application

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                 RELIASTAR LIFE INSURANCE COMPANY OF NEW YORK,
                    VARIABLE PRODUCT CUSTOMER SERVICE CENTER
                   1475 Dunwoody Drive West Chester, PA 19380
                                 1-800-963-9539

FG-EA-1000-08/97 (PE)                                                08/24/2001
                                                                         000000SERVICES AGREEMENT

     This Services Agreement (this "Agreement") is made effective as of
November 8, 1996 ("Effective Date"), by and between Directed Services, Inc.
("Company") and First Golden American Life Insurance Company of New York
("Provider").

     WHEREAS, Provider has extensive experience in life insurance business
operations; and

     WHEREAS, Company desires Provider to perform certain administrative and
special services (collectively, "services") for Company in its insurance
operations and desires further to make use in its day-to-day operations of
certain property, equipment and facilities (collectively, "facilities") of
Provider as Company may request; and

     WHEREAS, Provider and Company contemplate that such an arrangement will
achieve certain operating economies and improve services to the mutual benefit
of both; and

     WHEREAS, Provider and Company wish to assure that all charges for
services and the use of facilities incurred hereunder are reasonable and in
accordance with the requirements of New York Insurance Department; and

     WHEREAS, Provider and Company wish to identify the services to be
rendered to Company by Provider and the facilities to be used by Company and
to provide a method of fixing bases for determining the charges to be made to
Company;

     NOW, THEREFORE, in consideration of the premises and of the mutual
promises set forth herein, and intending to be legally bound hereby, Provider
and Company agree as follows:

1.   PERFORMANCE OF SERVICES AND USE OF FACILITIES.  Subject to the terms,
     conditions and limitations of this Agreement, Provider agrees to the
     extent requested by Company to perform diligently and in a professional
     manner such services for Company as Company determines to be reasonably
     necessary in the conduct of its insurance operations and as set forth in
     Section 2 of this Agreement.

     Subject to the terms, conditions and limitations of this Agreement,
     Provider agrees to the extent requested by Company to make available to
     Company such of its facilities as Company may determine to be reasonably
     necessary in the conduct of its insurance operations, including data
     processing equipment, business property (whether owned or leased) and
     communications equipment.

     Provider agrees at all times to maintain sufficient facilities and
     trained personnel of the kind necessary to perform this Agreement.

          (a)  CAPACITY OF PERSONNEL AND STATUS OF FACILITIES.  Whenever
          Provider utilizes its personnel to perform services for Company
          pursuant to this Agreement, such personnel shall at all times remain
          employees of Provider subject solely to its direction and control,
          and Provider shall alone retain full liability to such employees for
          their welfare, salaries, fringe benefits, legally required employer
          contributions and tax obligations.

               No facility of Provider used in performing services for or
          subject to use by Company shall be deemed to be transferred,
          assigned, conveyed or leased by performance or use pursuant to this
          Agreement.

          (b)  EXERCISE OF JUDGEMENT IN RENDERING SERVICES.  In providing any
          services hereunder which require the exercise of judgment by
          Provider, Provider shall perform any such service in accordance with
          any standards and guidelines Company develops and communicates to
          Provider.  In performing any services hereunder, Provider shall at
          all times act in a manner reasonably calculated to be in or not
          opposed to the best interests of Company.

          (c)  CONTROL.  The performance of services by Provider for Company
          pursuant to this Agreement shall in no way impair the absolute
          control of the business and operations of Provider or Company by
          their respective Boards of Directors.  Provider shall act hereunder
          so as to assure the separate operating identity of Company.

          (d)  USE OF DATA PROCESSING FACILITIES.  Subject to the terms
          (including any limitations and restrictions) of any applicable
          software or hardware licensing agreement then in effect between
          Provider and any licensor, Provider shall, upon termination of this
          Agreement, grant to Company a perpetual license, with payment of a
          reasonable fee, in any electronic data processing software developed
          or used by Provider in connection with the services provided to
          Company hereunder if such software is not commercially available and
          is necessary, in Company's reasonable judgment, for Company to
          perform subsequent to termination the functions provided by Provider
          hereunder.

2.   SERVICES.  The performance of Provider under this Agreement with respect
     to the business and operations of Company shall at all times be subject
     to the direction and control of the Board of Directors of Company.

     Subject to the foregoing and to the terms, conditions and limitations of
     this Agreement, Provider shall provide to Company the services set forth
     below.

          (a)  RECORDKEEPING.  Provider shall maintain detailed
          contract/customer level records tracking the units of each series in
          the GCG Trust that are purchased by the Separate Accounts of
          Provider.  Provider shall also keep address and ownership records
          for these units to enable the Company to satisfy its regulatory and
          contractual obligations.

          (b)  DISASTER RECOVERY PROGRAM.  Provider agrees to maintain back-up
          systems and contingency plans to assure that any work stoppages,
          interruptions, or other failures resulting from any types of
          disaster will not jeopardize the integrity of data or records
          maintained by Provider under this Agreement on behalf of the
          Company.  Provider warrants that it will maintain such systems and
          plans in conformity with prudent business practices.

3.   CHARGES.  Company agrees to reimburse Provider for services and
     facilities provided by Provider to Company pursuant to this Agreement.
     The charge to Company for such services and facilities shall include all
     direct and directly allocable expenses, reasonably and equitably
     determined to be attributable to Company by Provider, plus a reasonable
     charge for direct overhead, the amount of such charge for overhead to be
     agreed upon by the parties from time to time.

4.   PAYMENT.  Provider shall submit to Company within thirty (30) days of the
     end of each calendar month a written statement of the amount estimated to
     be owed by Company for services and the use of facilities pursuant to
     this Agreement in that calendar month, and Company shall pay to Provider
     within thirty (30) days following receipt of such written statement the
     amount set forth in the statement.

     Within thirty (30) days after the end of each calendar quarter, Provider
     will submit to Company a detailed written statement of the charges due
     from Company to Provider in the preceding calendar quarter, including
     charges not included in any previous statements, and any balance payable
     or to be refunded as shown in such statement shall be paid or refunded
     within fifteen (15) days following receipt of such written statement by
     Company.

5.   ACCOUNTING RECORDS AND DOCUMENTS.  Provider shall be responsible for
     maintaining full and accurate accounts and records of all services
     rendered and facilities used pursuant to this Agreement and such
     additional information as Company may reasonably request for purposes of
     its internal bookkeeping and accounting operations.  Provider shall keep
     such accounts and records insofar as they pertain to the computation of
     charges hereunder available at its principal offices for audit,
     inspection and copying by Company and persons authorized by it or any
     governmental agency having jurisdiction over Company during all
     reasonable business hours.

     With respect to accounting and statistical records prepared by Provider
     by reason of its performance under this Agreement, such records shall be
     delivered to Company within thirty (30) days from the end of the month to
     which the records pertain.

6.   OTHER RECORDS AND DOCUMENTS.  All books, records, and files established
     and maintained by Provider by reason of its performance under this
     Agreement which, absent this Agreement, would have been held by Company,
     shall be deemed the property of Company, and shall be subject to
     examination at all times by Company and persons authorized by it or any
     governmental agency having jurisdiction over Company, and shall be
     delivered to Company at least quarterly.

     With respect to original documents other than those provided for in
     Section 5 hereof which would otherwise be held by Company and which may
     be obtained by Provider in performing under this Agreement.  Provider
     shall deliver such documents to Company within thirty (30) days of their
     receipt by Provider except where continued custody of such original
     documents is necessary to perform hereunder.

7.   RIGHT TO CONTRACT WITH THIRD PARTIES.  Nothing herein shall be deemed to
     grant Provider an exclusive right to provide services to Company, and
     Company retains the right to contract with any third party, affiliated or
     unaffiliated, for the performance of services or for the use of
     facilities as are available to or have been requested by Company pursuant
     to this Agreement.

8.   CONTACT PERSON(S).  Company and Provider each shall appoint one or more
     individuals who shall serve as contact person(s) for the purpose of
     carrying out this Agreement.  Such contact person(s) shall be authorized
     to act on behalf of their respective parties as to the matters pertaining
     to this Agreement.  Effective upon execution of this Agreement, the
     initial contact person(s) shall be those set forth in Appendix A.  Each
     party shall notify the other, in writing, as to the name, address and
     telephone number of any replacement for any such designated contact
     person.

9.   TERMINATION AND MODIFICATION.  This Agreement shall remain in effect
     until terminated by either Provider or Company upon giving thirty (30)
     days or more advance written notice, provided that Company shall have the
     right to elect to continue to receive data processing services and/or to
     continue to utilize data processing facilities and related software for
     up to one year from the date of such notice.  Upon termination, Provider
     shall promptly deliver to Company all books and records that are, or are
     deemed by this Agreement to be, the property of Company.

10.  SETTLEMENT ON TERMINATION.  No later than ninety (90) days after the
     effective date of Complete Termination of this Agreement, Provider shall
     deliver to Company a detailed written statement for all charges incurred
     and not included in any previous statement to the effective date of
     termination.  The amount owed or to be refunded hereunder shall be due
     and payable within thirty (30) days of receipt of such statement.

11.  ASSIGNMENT.  This Agreement and any rights pursuant hereto shall not be
     assignable by either party hereto, except as set forth herein or by
     operation of law.  Except as and to the extent specifically provided in
     this Agreement, nothing in this Agreement, expressed or implied, is
     intended to confer on any person other than the parties hereto, or their
     respective legal successors, any rights, remedies, obligations or
     liabilities, or to relieve any person other than the parties hereto, or
     their respective legal successors, from any obligations or liabilities
     that would otherwise be applicable.  The representations, warranties,
     covenants and agreements contained in this Agreement shall be binding
     upon, extend to and inure to the benefit of the parties hereto, their,
     and each of their, successors and assigns respectively.

12.  GOVERNING LAW.  This Agreement shall be governed by and construed and
     enforced in accordance with the internal laws of the State of New York
     applicable to contracts made and to be performed in that State, without
     regard to principles of conflict of laws.

13.  ARBITRATION.  In the event of any irreconcilable dispute between the
     parties in connection with this Agreement, the dispute shall be submitted
     to arbitration. Either party may submit the dispute to arbitration by
     notifying the other of its submission and naming its arbitrator.  The
     other party shall name its arbitrator within 30 days after receiving such
     notice.  If the arbitrators cannot agree, they shall choose an umpire
     through the nomination of three persons by each arbitrator, the
     declination by each arbitrator of two of the nominees named by the other
     arbitrator and the drawing of lots to choose between the two arbitrators
     within thirty days after the arbitrators and umpire, if any, are chosen.
     The arbitrators and umpire shall be disinterested insurance company
     executives.  The arbitrators are relieved from judicial formalities and
     may refrain from following strict rules of evidence.  The decisions of
     the arbitrators and umpire, or the majority of them, shall be final and
     binding upon the parties.  Each party shall bear the expense of its own
     arbitrator and one-half the other expenses of the arbitration
     proceedings.  Any arbitration shall take place in New York, New York,
     unless otherwise mutually agreed.

14.  NOTICE.  All notices, statements or requests provided for hereunder shall
     be deemed to have been duly given when delivered by hand to an officer of
     the other party, or when deposited with the U.S. Postal Service, as first
     class certified or registered mail, postage prepaid, overnight courier
     service, telex or telecopier, addressed:

     (a)  if to Provider:

          Mary Bea Wilkinson
          First Golden American Life Insurance
             Company of New York
          1001 Jefferson Street, Suite 400
          Wilmington, Delaware  19801
     (b)  if to Company:

          Myles R. Tashman
          Directed Services, Inc.
          1001 Jefferson Street, Suite 400
          Wilmington, Delaware  19801

     or to such other persons or places as each party may from time to time
     designate by written notice sent as aforesaid.

15.  ENTIRE AGREEMENT.  This Agreement, together with such amendments as may
     from time to time be executed in writing by the parties, constitutes the
     entire Agreement and understanding between the parties in respect of the
     transactions contemplated hereby and supersedes all prior agreements,
     arrangements and understandings relating to the subject matter hereof.
     Any amendments to this Agreement are subject to prior approval by the
     Superintendent, State of New York, Department of Insurance.

16.  SECTION HEADINGS.  Section headings contained herein are for reference
     purposes only and shall not affect the meaning or interpretation of this
     Agreement.

17.  COUNTERPARTS.  This Agreement may be executed in separate counterparts,
     each of which shall be deemed an original, but all of which together
     shall constitute one and the same instrument.

18.  ADDITIONAL PROVISIONS.  Appendix A, attached hereto, is hereby
     incorporated into and made a part of this Agreement.

     IN WITNESS WHEREOF, the parties have caused this Agreement to be executed
in duplicate by their respective officers duly authorized so to do, and their
respective corporate seals to be affixed hereto, as of the date and year first
above written.

DIRECTED SERVICES, INC.

          /s/  Mary Bea Wilkinson
          ----------------------------------------
          Mary Bea Wilkinson, President                (Seal)

Attest:   /s/  Myles R. Tashman
          ----------------------------------------
          Myles R. Tashman, Secretary

FIRST GOLDEN AMERICAN LIFE INSURANCE COMPANY OF NEW YORK

          /s/  Terry L. Kendall
          ----------------------------------------
          Terry L. Kendall, President                  (Seal)

Attest:   /s/  Myles R. Tashman
          ----------------------------------------
          Myles R. Tashman, Secretary

                                  APPENDIX A

                        CONTACT PERSON(S) FOR PROVIDER

                              Mary Bea Wilkinson

                         CONTACT PERSON(S) FOR COMPANY

                               Myles R. Tashman

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