Document:

FIRST GOLDEN AMERICAN                                      FLEXIBLE PREMIUM
LIFE INSURANCE COMPANY OF NEW YORK            DEFERRED COMBINATION VARIABLE
                                              AND FIXED ANNUITY APPLICATION
FIRST GOLDEN AMERICAN LIFE INSURANCE COMPANY OF NEW YORK IS A STOCK
  COMPANY DOMICILED IN NEW YORK, NEW YORK

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

---------------------------------------------------------------------------
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.#
                         / /        / /
---------------------------------------------------------------------------
Permanent Address        Phone (   )

---------------------------------------------------------------------------
City                     State     Zip       Date of Birth  Relation
                                                            to Owner
===========================================================================
     CONTINGENT ANNUITANT (OPTIONAL)
---------------------------------------------------------------------------
Name                               Address                  Relation
                                                            to Owner
---------------------------------------------------------------------------
3.   PRIMARY BENEFICIARY(IES)      (IF MORE THAN ONE - INDICATE %)
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Name(s)                                                     Relation
                                                            to Owner
---------------------------------------------------------------------------
   CONTINGENT BENEFICIARY(IES)     Name                     Relation
                                                            to Owner
---------------------------------------------------------------------------
4.   PLAN
---------------------------------------------------------------------------
     / / DVA PLUS
---------------------------------------------------------------------------
5.   DEATH BENEFIT OPTIONS
---------------------------------------------------------------------------
     / / Annual Ratchet           / / Standard
---------------------------------------------------------------------------
6.   INITIAL PREMIUM AND ALLOCATION INFORMATION
---------------------------------------------------------------------------
     (A)  INITIAL PREMIUM PAID $__________ MAKE CHECK PAYABLE TO FIRST
          GOLDEN AMERICAN 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>

     ACCOUNT DIVISION                  INVESTMENT ADVISER                 (A) INITIAL
<S>                                <C>                                    <C>

OTC                                MASSACHUSETTS FINANCIAL SERVICES                 %
                                      COMPANY (MFS)
RESEARCH                           MASSACHUSETTS FINANCIAL SERVICES                 %
                                      COMPANY (MFS)
TOTAL RETURN                       MASSACHUSETTS FINANCIAL SERVICES                 %
                                      COMPANY (MFS)

INCOME AND GROWTH                  SMITH BARNEY MUTUAL FUND MANAGEMENT INC.         %
INTERNATIONAL EQUITY               SMITH BARNEY MUTUAL FUND MANAGEMENT INC.         %
HIGH INCOME                        SMITH BARNEY MUTUAL FUND MANAGEMENT INC.         %
MONEY MARKET                       SMITH BARNEY MUTUAL FUND MANAGEMENT INC.         %

APPRECIATION                       SMITH BARNEY MUTUAL FUND MANAGEMENT INC.         %

HIGH GROWTH                        TRAVELERS INVESTMENT ADVISOR, INC.               %
GROWTH                             TRAVELERS INVESTMENT ADVISOR, INC.               %
BALANCED                           TRAVELERS INVESTMENT ADVISOR, INC.               %
CONSERVATIVE                       TRAVELERS INVESTMENT ADVISOR, INC.               %
INCOME                             TRAVELERS INVESTMENT ADVISOR, INC.               %

FIXED ALLOCATION ELECTION           1-YEAR                                          %
FIXED ALLOCATION ELECTION           3-YEAR                                          %
FIXED ALLOCATION ELECTION           5-YEAR                                          %
FIXED ALLOCATION ELECTION           7-YEAR                                          %
FIXED ALLOCATION ELECTION          10-YEAR                                          %
                                        TOTAL                                    100%
</Table>

   First Golden American Life Insurance Company of New York, Variable
    Products Service Center, PO Box 8794, Wilmington, DE 19899-8794

FG-AA-1000-12/95(PE)

<Page>

---------------------------------------------------------------------------
7.   OPTIONAL SYSTEMATIC PARTIAL WITHDRAWALS
---------------------------------------------------------------------------
     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: 1-800-366-0066.
---------------------------------------------------------------------------
8.   TAX-QUALIFIED PLANS  If you are funding a qualified plan, please
          specify type.
---------------------------------------------------------------------------
     / / IRA     / / IRA Rollover     / / SEP/IRA
     / / Other  ________________________
---------------------------------------------------------------------------
9.   REPLACEMENT
---------------------------------------------------------------------------
     Will the coverage applied for replace any existing annuity or life
     insurance policies on the annuitant's life?

     / / Yes (If yes, please complete following)      / / No
---------------------------------------------------------------------------
Company Name                             Policy Number       Face Amount
---------------------------------------------------------------------------

---------------------------------------------------------------------------
10.  READ THE FOLLOWING STATEMENTS CAREFULLY AND SIGN BELOW:

     - 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.

     - 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 FIRST
     GOLDEN AMERICAN HAVE THE AUTHORITY TO MODIFY THIS APPLICATION.

     - 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 (if other than       Signed at (City, State)  Date
                         owner)

Client Account No. (if applicable)_____________________
---------------------------------------------------------------------------
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

__________________________   ________________________   ___________________
Agent Signature              Print Agent Name & No.     Social Security No.

__________________________________
Broker/Dealer/Branch
---------------------------------------------------------------------------

---------------------------------------------------------------------------
Amendment to Application
---------------------------------------------------------------------------

---------------------------------------------------------------------------

---------------------------------------------------------------------------

---------------------------------------------------------------------------

   First Golden American Life Insurance Company of New York, Variable
    Products Service Center, PO Box 8794, Wilmington, DE 19899-8794
                           1-800-366-0066

FG-AA-1000-12/95(PE)RELIASTAR                                     FLEXIBLE PREMIUM
LIFE INSURANCE COMPANY OF NEW YORK            DEFERRED COMBINATION VARIABLE
                                              AND FIXED ANNUITY APPLICATION

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

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

---------------------------------------------------------------------------
City                     State     Zip       Date of Birth

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

---------------------------------------------------------------------------
City                     State     Zip       Date of Birth  Relation
                                                            to Owner
===========================================================================
     CONTINGENT ANNUITANT (OPTIONAL)
---------------------------------------------------------------------------
Name                               Address                  Relation
                                                            to Owner
---------------------------------------------------------------------------
3.   PRIMARY BENEFICIARY(IES)      (IF MORE THAN ONE - INDICATE %)
---------------------------------------------------------------------------
Name(s)                                                     Relation
                                                            to Owner
---------------------------------------------------------------------------
   CONTINGENT BENEFICIARY(IES)     Name                     Relation
                                                            to Owner
---------------------------------------------------------------------------
4.   PLAN
---------------------------------------------------------------------------
     / / DVA PLUS
---------------------------------------------------------------------------
5.   DEATH BENEFIT OPTIONS
---------------------------------------------------------------------------
     / / Annual Ratchet           / / Standard
---------------------------------------------------------------------------
6.   INITIAL PREMIUM AND ALLOCATION INFORMATION
---------------------------------------------------------------------------
     (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>
-------------------------------------------------------------------------------------
     ACCOUNT DIVISION                  INVESTMENT ADVISER                 (A) INITIAL
-------------------------------------------------------------------------------------
<S>                                <C>                                        <C>
CAPITAL APPRECIATION               A I M CAPITAL MANAGEMENT,INC.              %
-------------------------------------------------------------------------------------
STRATEGIC EQUITY                   A I M CAPITAL MANAGEMENT,INC.              %
-------------------------------------------------------------------------------------
CAPITAL GROWTH                     ALLIANCE CAPITAL MANAGEMENT,LP             %
-------------------------------------------------------------------------------------
DEVELOPING WORLD                   BARING INTERNATIONAL INVESTMENT LIMITED    %
-------------------------------------------------------------------------------------
HARD ASSETS                        BARING INTERNATIONAL INVESTMENT LIMITED    %
-------------------------------------------------------------------------------------
LARGE CAP VALUE                    CAPITAL GUARDIAN TRUST COMPANY             %
-------------------------------------------------------------------------------------
MANAGED GLOBAL                     CAPITAL GUARDIAN TRUST COMPANY             %
-------------------------------------------------------------------------------------
SMALL CAP                          CAPITAL GUARDIAN TRUST COMPANY             %
-------------------------------------------------------------------------------------
VALUE EQUITY                       EAGLE ASSET MANAGEMENT,INC.                %
-------------------------------------------------------------------------------------
DIVERSIFIED MID-CAP                FIDELITY MANAGEMENT & RESEARCH COMPANY     %
-------------------------------------------------------------------------------------
ASSET ALLOCATION GROWTH            FIDELITY MANAGEMENT & RESEARCH COMPANY     %
-------------------------------------------------------------------------------------
INTERNET TOLLKEEPER                GOLDMAN SACHS ASSET MANAGEMENT             %
-------------------------------------------------------------------------------------
PILGRIM WORLDWIDE GROWTH FUND      ING INVESTMENT MANAGEMENT ADVISORS B.V.    %
-------------------------------------------------------------------------------------
LIMITED MATURITY BOND              ING INVESTMENT MANAGEMENT,LLC              %
-------------------------------------------------------------------------------------
LIQUID ASSET                       ING INVESTMENT MANAGEMENT,LLC              %
-------------------------------------------------------------------------------------
PILGRIM VP GROWTH OPPORTUNITIES    ING PILGRIM INVESTMENTS,LLC                %
-------------------------------------------------------------------------------------
PILGRIM VP MAGNACAP PORTFOLIO      ING PILGRIM INVESTMENTS,LLC                %
-------------------------------------------------------------------------------------
PILGRIM VP SMALLCAP OPPORTUNITIES  ING PILGRIM INVESTMENTS,LLC                %
-------------------------------------------------------------------------------------
GROWTH                             JANUS CAPITAL CORPORATION                  %
-------------------------------------------------------------------------------------
GROWTH AND INCOME                  JANUS CAPITAL CORPORATION                  %
-------------------------------------------------------------------------------------
SPECIAL SITUATIONS                 JANUS CAPITAL CORPORATION                  %
-------------------------------------------------------------------------------------
PRUDENTIAL JENNISON                JENNISON ASSOCIATES LLC                    %
-------------------------------------------------------------------------------------
SP JENNISON INTERNATIONAL GROWTH   JENNISON ASSOCIATES LLC                    %
-------------------------------------------------------------------------------------
RISING DIVIDENDS                   KAYNE ANDERSON INVESTMENT MANAGEMENT,LLC   %
-------------------------------------------------------------------------------------
MID-CAP GROWTH                     MFS INVESTMENT MANAGEMENT (R)              %
-------------------------------------------------------------------------------------
RESEARCH                           MFS INVESTMENT MANAGEMENT (R)              %
-------------------------------------------------------------------------------------
TOTAL RETURN                       MFS INVESTMENT MANAGEMENT (R)              %
-------------------------------------------------------------------------------------
CORE BOND                          PACIFIC INVESTMENT MANAGEMENT COMPANY      %
-------------------------------------------------------------------------------------
PIMCO HIGH YIELD BOND              PACIFIC INVESTMENT MANAGEMENT COMPANY      %
-------------------------------------------------------------------------------------
PIMCO STOCKSPLUS GROWTH & INCOME   PACIFIC INVESTMENT MANAGEMENT COMPANY      %
-------------------------------------------------------------------------------------
PROFUND VP BULL                    PROFUND ADVISORS,LLC                       %
-------------------------------------------------------------------------------------
PROFUND VP SMALL CAP               PROFUND ADVISORS,LLC                       %
-------------------------------------------------------------------------------------
PROFUND VP EUROPE 30               PROFUND ADVISORS,LLC                       %
-------------------------------------------------------------------------------------
REAL ESTATE                        PRUDENTIAL INVESTMENT CORPORATION          %
-------------------------------------------------------------------------------------
ALL CAP                            SALOMON BROTHERS ASSET MANAGEMENT INC.     %
-------------------------------------------------------------------------------------
INVESTORS                          SALOMON BROTHERS ASSET MANAGEMENT INC.     %
-------------------------------------------------------------------------------------
EQUITY INCOME                      T.ROWE PRICE ASSOCIATES,INC.               %
-------------------------------------------------------------------------------------
FULLY MANAGED                      T.ROWE PRICE ASSOCIATES,INC.               %
-------------------------------------------------------------------------------------
FIXED ALLOCATIONS:                 o _____________OTHER                       %
-------------------------------------------------------------------------------------
FIXED ALLOCATIONS:                 o 1 YR  o 3 YR  o 5 YR  o 7 YR o 10 YR     %
-------------------------------------------------------------------------------------
                                   TOTAL                                    100%
-------------------------------------------------------------------------------------
</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-AA-1000-10/00                                                     08/24/2001
                                                                         000000

<PAGE>

---------------------------------------------------------------------------
7. OPTIONAL SYSTEMATIC PARTIAL WITHDRAWALS
---------------------------------------------------------------------------
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.
---------------------------------------------------------------------------
8. TAX-QUALIFIED PLANS If you are funding a qualified plan, please specify
   type:
---------------------------------------------------------------------------
     / / IRA    / / IRA Rollover    / / SEP/IRA    / /Other _______________
---------------------------------------------------------------------------
9. REPLACEMENT
Will the coverage applied for replace any existing annuity or life
insurance policies on the annuitant's life?
---------------------------------------------------------------------------
     / / Yes (If yes, please complete following.)       / / No
---------------------------------------------------------------------------
Company Name                 Policy Number                      Face Amount

---------------------------------------------------------------------------

---------------------------------------------------------------------------
10. READ THE FOLLOWING STATEMENTS CAREFULLY AND SIGN BELOW:
---------------------------------------------------------------------------

     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)_____________________
---------------------------------------------------------------------------
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
---------------------------------------------------------------------------

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

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

Amendment to Application

---------------------------------------------------------------------------
---------------------------------------------------------------------------
---------------------------------------------------------------------------
---------------------------------------------------------------------------
---------------------------------------------------------------------------

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

FG-AA-1000-10/00                                                 08/24/2001
                                                                     000000

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