Loading...
HomeMy WebLinkAboutC-3819 - Plan Sponsor Submission Information• Plan Sponsor Submission ING Information ING Health Reserve Account (KRA) ING Life Insurance and Annuity Company 151 Farmington Avenue Hartford, CT 06156 -6022 Fax: 860-723-9673 ING Life Insurance and Annuity Company (ILIAC), ING National Trust and ING Financial Advisers, LLC (member SIPC) may be referred to as ING. Submit with Application. Part 1 - Case Profile Contract Contract HolderTrustee Name Holder/Trustee Citv of ort Beach Information Address (No. & Street /PO Box) 3300 Newport Boulevard /P.O. Box 1768 Form No. 62362 Non -ERISA Gov HRA (121D12DO5) Page 1 of 9 — Incomplete without an pages CityTown State ZIP Newport Beach CA 92663 Plan Sponsor or Plan Sponsor or Named Fiduciary Name Named Fid I Cit of Newport Beach Information Address (No. & Street/P0 Box, City/Town, State, ZIP) 3300 Newport Boulevard /P.O. Box 1768, Newport Beach CA Contact Name and Phone Number Richard C. Kurth 949) 644 -3124 If ING is not the exclusive provider, list the names of other carriers: Market ❑ Healthcare ❑ Education ® Government (non ERISA public employers only) Trust Type ❑ VEBA, IRC Section 501(c)(9) ® IRO Section 115 Contributions Contribution Frequency (check at/ that apply) Employer ❑ Annually ❑ Quarterty ❑ Monthly (3 Semi - Monthly ® Bi- Weekly ❑ Weekly Total Number of Eligible Employees Ron Total Takeover Plan Assets A Estimated I` year Enrollment (Number of Participants) 90r) B. Estimated Average Annual Amount (Contribution per Participant) ER 41,2_40. 00 C. Estimated 1 ° Year Cash Flow (A x B) ER C qC)2 000.00 Special Does this case require any special Case Notations regarding processing restrictions? Requests Contract Is this Contract to be linked with an existing Master Billing Group? ❑ Yes gNo Administration If Yes, indicate Master Billing Group No. Forfeiture Account A forfeiture account will be established upon notification from the Plan Sponsor to ING of a participant's benefit forfeiture in accordance with the terms of the plan. Assets will be invested in this account as follows until disposed of in accordance with the terms of the plan document: 100 % N. Fixed Account Fund HRA HRA Administrative Agent Name Telephone No. Administrative Administration Resources Corp. (763> 421 -5510 Agent Information Address (No. & Stroet/PO Box, Crty/TDm, State, ZIP) 11490 Xeon Street NW, Suite 200, Coon Rapids, MN 55448 -3149 Daily Asset Charge The Daily Asset Charge applies to the variable investment options only. The charge does not include Mutual Fund Investment Advisory and Administrative Fees or other fund operating expenses. These separate expenses are added to the Daily Asset Charge to determine the total cost of the variable investment options. Fees The Daily Asset Charge will be 0.70% . The Maintenance Fee will be S30.00 (fhe maintenance fee will be deducted on a pro -rata basis from each account in which there is an interest, and will only apply to allocated accounts.) See separate agreement regarding fees for administrative services. Form No. 62362 Non -ERISA Gov HRA (121D12DO5) Page 1 of 9 — Incomplete without an pages Form No. 62362 Non -ERISA Gov HRA (12/012005) Page 2 of 9 - incomplete without all pages Compensation Compensation will be paid in the following manner: 0 % of Contributions in the First Case Year 0 % of Transferred Assets in the First Case Year _---L% Based Commissions for Case Years 1 through 5 starting in Case Month 13 Fees Paid to ING ING receives payments from mutual fund investment managers: by Mutual Funds 12b -1 Fees: Some funds offered under our products pay ING Financial Advisers, LLC a fee ranging from 0.15 % - 0.50% of assets in their applicable funds for distrbution and other services provided on behalf of those funds. These fees (sometimes referred to as "12b -1 Fees) vary from fund to fund. Administration and Other Fees: ING receives, or may receive, fees of up to $12 per Participant per Fund from one or more of the applicable funds. Alternatively, ING may receive up to 0.425% of assets in administrative fees from one or more of the applicable funds. These fees, where received, cover the fallowing types of administrative services only and do not constitute payment for investment advisory services or costs of distribution: accounting, recordkeeping, prospectus printing and/or delivery/mailing, proxy printing and /or mailing and tabulation, periodic fund reports printing and /or mailing. For information on which funds pay ING such fees and at what level, please consult your ING Representative. Written confirmation will be provided upon request. Other Mutual Fund Pees and Expenses: The charges listed above do not include mutual fund investment advisory fees or other fund operating expenses. Please refer to the mutual fund prospectuses and investment option summaries for more complete information about all expenses and fees. Fees and Charges Transferred Asset Benefit (TAB) is available to compensate for cancellation penalties imposed by your Plan's for Transferrred present financial provider when you transfer your Plan's assets to the ING HRA Contract. When the TAB feature Asset Benefit is elected, ING will apply a TAB amount of up to 7% of the assets transferred to the HRA Contract. To be eligible (TAB) Option for TAB, ING must be the exclusive provider for all contributions to the Plan. (Requires Product If you elect the Transferred Asset Benefit (TAB) to absorb surrender charges paid by the plan to a prior carrier, Manager Approval) your Daily Asset Charge (DAC) will be increased by up to 0.35% of assets and your ING Fixed Account credited rate will be reduced by the same amount. You may be subject to a TAB Recovery Charge for up to 5 years. Please ask your ING representative for additional information regarding this feature. Will the TAB option be offered? OYes 0 No If Yes is selected above, the completed TAB request letter and TAB approval letter must accompany this paperwork. Form No. 62362 Non -ERISA Gov HRA (12/012005) Page 2 of 9 - incomplete without all pages and Enrollments P ING will create participant accounts and invest assets in accordance with fund replacement instructions to be provided by the Plan Sponsor or Named Fiduciary in conjunction with account information provided by the existing investment provider. The Plan Sponsor or Named Fiduciary, by executing this form, acknowledges that they understand the terms that apply to the investment options available under the contract, accept responsibility for these investment directions on participants' behalf consistent with the terms of the plan and agree to indemnify and hold ING harmless from any claim that may arise from investing these funds as it has directed. The Plan Sponsor or Named Fiduciary, by executing this form, takes full responsibility for communicating all changes to plan participants. All plan participants will receive ING's contract disclosure material, fund one -page summaries and fund performance in a Participant Guide. They will be informed that fund prospectuses are available by calling their local representative. The participants will be instructed to use ING's 900 number or ING Access on the Internet to view account balance information, process fund transfers (movement of existing assets) and/or allocation changes (the direction of future contributions), after the effective date of this transfer. ING must receive the appropriate information in an automated format from the existing provider. This Takeover Process will • Establish participant accounts to receive contributions with investment allocations based on fund replacement instructions received from the Plan Sponsor and account information provided by the exisfing provider. The automated file from the existing provider, via an Excel file must include each Participant's name, address, Social Security Number, birth date, gender and allocation information indicating the specific investments and their whole percentages. Upon receipt of a file in good order containing this information, ING will establish accounts based on the investment allocations indicated and the fund replacement instructions from the Plan Sponsor. Any employee that currently does not have an account with the existing provider and will be enrolling in the plan for the fast time will be enrolled according to the enrollment process for new participants. • Hold assets in an unallocated account if Participant accounts are not established before assets are transferred from the current carrier, and/or investment instructions at a participant level are not provided on the day the wire is received. For investment into the unallocated account, ING is instructed to accept taxed investment information from the existing provider, broker or existing HRA Administrative Agent on the day the wire is received by ILIAC. The responsible party will fax ING an accounting by investment opfion of the existing assets at a Plan level, as of liquidation. These assets will be deposited into the plan level Unallocated Asset Account according to the fund replacement instructions provided by the Plan Sponsor at or before the liquidation. If assets are received without instructions, they will remain un- invested pending this information. • Invest assets at the Participant level as follows: (check one) ® ING Fixed Account or ❑ Pursuant to the attached instructions provided by the Plan Sponsor or Named Fiduciary or the existing HRA Adminstrative Agent or existing provider, Any Participant reallocation information provided by fund must be equal to the investment by fund in the unallocated account in order to accurately invest the assets. We will allocate the assets for all Participants on the date of receipt of the instructions if they are received in good order on a business day prior to the final close of the New York Stock Exchange (NYSE), generally, 4:00 PM Eastern Time. Assets received in good order after the final dose of the NYSE or on a non - business day will be processed the next day that the NYSE is open. If assets are not applied into specific investments according to fund replacement instructions, any interest earned while waiting for reallocation instructions will be posted to the Participant accounts the first business day following the reallocation of the principal. Unless other instructions are provided, we will determine the amount of interest to be posted to each Participant account on a pro -rata basis that utilizes the amount of principal to determine the The Plan Sponsor or Named Fiduciary authorizes ING to enroll new participants in the Funding Agreement and allocate their contributions to the ING Fixed Account, until such time that the participant makes an allocation change, if permitted. Prior to ING's acceptance of contributions, the Plan Sponsor or Named Fiduciary agrees to provide the following information: • SSN • Name • Address • Date of Birth • Gender Form No. 62362 Non -ERISA Gov HRA (121012005) Page 3 of 9 - Incomplete without all pages 0 0 Part 1 — Case Profile - Continued Fund Selections ❑ Select all the funds listed below. ® Select only the funds chosen below which must include the ING Fixed Account ❑ ING Fixed Account Only Stability of Principal ® [598] ING Fixed Account Bonds ❑ [363] ING GNMA Income Fund - Class A ❑ [463] ING Government Fund - Class A ® [497] ING Intermediate Bond Fund - Class A ❑ [304] Lord Abbett Bond -Debenture Fund, Inc. - Class P ❑ [928] Pioneer High Yield Fund - Class R ® [501] Pioneer Strategic Income Fund - Class R Asset Allocation ® [469] ING Strategic Allocation Balanced Fund - Class A ® [46B] ING Strategic Allocation Growth Fund - Class A ® 1470] ING Strategic Allocation Income Fund - Class A Balanced ❑ [474] ING Balanced Fund - Class A ® [193] Pax World Balanced Fund Large Cap Value ❑ [201] AIM Basic Value Fund - Class R ❑ [223] AIM Charter Fund - Class R ❑ [326] American Century@ Equity Income Fund - Class R JR [329] American Century® Large Company Value Fund - Class R ❑ [472] ING Equity Income Fund - Class A ❑ [4851 ING Index Plus LargeCap Fund - Class A ❑ [245] ING MagnaCap Fund - Class A ❑ [491) ING Value Opportunity Fund - Class A ❑ [351] Oppenheimer Main Street Fund*- Class N ® [357] Mutual Shares Fund - Class R ❑ [980) Pioneer Equity Income Fund - Class R ❑ [988] Pioneer Fund - Class R Large Cap Growth ❑ [204] AIM Constellation Fund - Class R ❑ [328] American Century@ Growth Fund - Class R ❑ [325] American Century@ Ultra@ Fund - Class R ❑ [471] ING Growth Fund - Class A ❑ [246[ ING LargeCap Growth Fund - Class A ® [349] Oppenheimer Capital Appreciation Fund - Class N ❑ [516] Pioneer Growth Shares - Class R ® [837) TCW Galileo Select Equities Fund - Class K Smalumidlspecialty ❑ [202] AIM Mid Cap Core Equity Fund - Class R ❑ [295] AIM Small Cap Growth Fund - Class R ® F1 5] Allianz CCM Mid -Cap Fund - Class R ❑ [355] Franklin Rising Dividends Fund - Class R ❑ [354] Franklin Small-Mid Cap Growth Fund - Class R ❑ (360] Franklin Utilities Fund - Class R ❑ [458] ING Financial Services Fund - Class A ❑ [197) ING Global Science and Technology Fund - Class A ® [489] ING Index Plus MidCap Fund - Class A ® [493] ING Index Plus SmallCap Fund - Class A ❑ [428] ING MidCap Opportunities Fund - Class A ❑ [292] ING Real Estate Fund - Class A ❑ [473] ING Small Company Fund - Class A ❑ [365] ING SmallCap Opportunities Fund - Class A ❑ [305] Lord Abbett Developing Growth Fund, Inc - Class P ® [301) Lord Abbett Growth Opportunities Fund - Class P ® [352] Oppenheimer Main Street* Small Cap Fund - Class N ❑ [324] Pioneer Mid Cap Value Fund - Class R ❑ [836) TCW Galileo Opportunity Fund - Class K ❑ [635) TCW Galileo Value Opportunities Fund - Class K GlobaVlntemational Growth ❑ [327] American Century® International Growth Fund - Class R ❑ [313] ING Emerging Countries Fund - Class Q ❑ [364) ING Global Value Choice Fund - Class A ❑ [498) ING Intemational Fund - Class Q ❑ [366] ING Intemational SmallCap Growth Fund - Class A ® [356) Mutual Discovery Fund - Class R ❑ [350] Oppenheimer Global Fund - Class N ❑ [358) Templeton Developing Markets Trust - Class R ® [359] Templeton Foreign Fund - Class R Proprietary Funds: Shares of the ING Funds are not insured by the Federal Deposit Insurance Corporation; Shares of the ING Funds are not deposits or other obligations of ING National Trust or any of its affiliates; Shares of the ING Funds are not obligations of, and are not guaranteed by the U.S. government, its agencies or instrumentalities; The ING Funds involve investment risks, including possible loss of principal amount invested; and ING Investment Management, Inc., (IIM), an affiliate of ING and ING National Trust, ads as investment advisor to, and shareholder servicing agent for, the ING - advised funds listed above, and provides other services for these funds. IIM receives fees for providing these services, as described in the fund prospectuses. Form No. 82362 Non -ERISA Gov HRA (1210112005) Page 4 of 9 - Incomplete without all pages 0 Pian Name Part 2 — Data Remittance and 0 Data Remittance To ensure accuracy and timeliness in Me processing of Plan Contributions, ING offers 3 options. Select only one method you wish to use ING requires one (1) of three (3) methods to accommodate your submission of census and contribution remittances ❑ Voice Response Unit (VRU) ® Internet File Transfer (IFT) ❑ Internet Direct Payment Date of first contribution submission to ING: 1 -12 -06 Submission frequency by location and source: evary two weeks Deposit Method You must select only one Deposit Method ® ACH Debit - Money is electronically transferred from the Plan Sponso's Bank Account to ING when remittance data is received (ACH Debit Section must be completed). ❑ ACH Credit - Plan Sponsor initiates electronic transfer of money, which is received the following business day by ING. ❑ Wire Transfer - Plan Sponsor initiates money transfer to ING via federal reserve system. Automated Clearing House (ACH) Debit Account Information ING will access the bank account below upon receipt of remittance data and will process an Automated Clearing House (ACH) debit transaction from the customer account. Funds will be transferred to the Operating Account at Wachovia Bank in Winston -Salem, North Carolina. In consideration of your participation in this Plan, in the unlikely event of an ACH debit error, ING agrees to indemnify and hold the Customer harmless from any loss you may suffer from the above transaction. This authorization applies to all of the subsidiaries and affiliates of the Customer and is effective immediately. Temenabon of this Agreement must be submitted in writing and Adfl be effective upon receipt of written request by ING. Bank account information can be updated by the customer via ING approved mediums that have been made available to the customer (VRU/(ntemet Direct Payment) or by contacting ING at BDO- 23M212. ING will confirm to the Customer when bank account information has been updated. Upon receipt of your bank account information, ING will process a "pre-note" $0.00 transaction to verify account information. This takes approximately ten (10) business days from the date ING receives this completed form. Once all Information is acknowledged for accuracy, ING PAY thereafter access Customer bank account each fime remittance information is sent to ING by the Customer for an amount which may vary from time to time. Customer will verify amount through selected remittance medium. ACH Debit Confirmation Election If you have selected ACH Debit as your payment method, ING will return a confirmation of receipt upon processing your remittance. Please indicate below your preference for receiving this confirmation. ❑ Mail Back - Written confirmation mailed to the following address (No. & Street /PO Box, City/Town, State, ZIP): Fax Back — Confirmation sent to Fax No (include area code) E-Mail — Confirmation sent to E -Mail Address dkurth @city.newport— beach.ca.us and kwills@city.newport— beach.ca.us Form No. 82362 Non -ERISA Gov HRA (1210112DD5) Page 5 of 9 — Inwmplete without all pages Plan Sponsor or Named Fiduciary Responsibilities • • • Authorized Designee for purposes of authorizing HRA administrator fees. • Select a plan design that best meets Plan Sponsor's benefit objectives. • Choose investment options from those available under the funding vehicle. • Assume overall responsibility for HRA operation. • Appoint an HRA Administrative Agent. • Electronically provide ING with completed enrollment information. • Provide ING with all required New Business Plan Sponsor Submission paperwork, including but not limited to the signed contract application and signed Plan Sponsor Submission paperwork • Review plan document and all other plan related documents with your tax and legal counsel. • Review and maintain all documents, data and reports provided by ING and/or the HRA Administrative Agent • Initiate any asset transfer activity p. e., transfer from existing investment provider to ING) by providing current custodian or trustee with liquidation letter and any other required documentation. • Initiate electronic fund transfer of contributions. • Provide contribution data in an automated format. • Ensure accuracy of allocation data provided by the Plan Sponsor, Named Fiduciary or existing HRA Administrative Agent and/or previous investment provider in case of transferred assets. • Review and reconcile contribution information. • Provide newly eligible individual enrollment information to ING before funds are deposited into the contract. • Authorize HRA Administrative Agent to initiate plan disbursements and ensure accuracy of information provided to ING. Plan Sponsor or Named Fiduciary Responsibilities delegated to the HRA Administrator • Authorize HRA Administrator to collect administration fees from participant accounts when applicable under the Administrative Services Agreement. • Prepare Plan and Trust documents, if applicable, for Plan Sponsor approval. • Establish capability to receive participant level data from ING. • Provide plan specification and related HRA design consulting. • Perform discrimination testing as required under applicable federal law to assist plan sponsor in complying with federal qualification requirements for your Plan. • Administer plan in accordance with the plan document, trust agreement and all applicable federal and state laws and regulations including but not limited to the requirements of the Internal Revenue Code (IRC). • Communicate plan and plan related changes, and answer plan- related questions from participants. • Provide participant benefit statements. • Obtain appropriate statement from sponsor and /or participant representing that request for qualified medical reimbursement has not and will not be the subject of (1) a duplicate claim request or (2) any type of claim from an HRA, Flexible Spending Arrangement (FSA), or other medical expense payment or reimbursement plan. • Test and monitor for participation, nondiscrimination and contribution limits compliance as applicable. Provide technical support and guidance to Plan Sponsors regarding legislative and regulatory changes, their impact on the program and provide recommendations for appropriate modifications if necessary. • Determine eligibility and qualification for all plan disbursements and submit requests to ING using secured methods as agreed upon by both parties. • Obtain annual Level II SAS 70 audit report and make available to Plan Sponsor and ING. • Maintain Errors and Omissions insurance of at least $1 million per occurrence and $2 million in the aggregate and provide evidence of such coverage at any time upon the request of ING. • Maintain a Fidelity Bond or Commercial Crime insurance of at least $1 million per occurrence and $2 million in the aggregate and provide evidence of such coverage at any time upon request of ING. • Generate any required Payee Statements and Information Returns under HRA Administrator's Employer Identification Number (EIN) as required. • Provide timely claims processing including any adjudication where necessary. • Distribute reimbursements to participants. • Provide plan participants with a call center and transaction web site with links to ING's web site and call center. • Collect and maintain participant dependent information. • Complete and file IRS Form 990 as required. Form No. 82362 Non•ERISA Gov HRA (12MI12005) Page 6 of 9 — Incomplete without all pages Plan Sponsor or Named Fiduciary Name (please type or print) I Tax ID No. Form No. 82362 Non -ERISA Gov HRA (121012005) Page 7 of 9 — Incomplete without all pages ING Respond to HRA product questions from Plan Sponsors or Named Fiduciaries and producers. Responsibilities Provide HRA product literature (hard copy and web - based). Distribute welcome packets to Plan Sponsors and participants. As applicable, fulfill HRA Administrative Agent request for participant data maintained by ING and required by the HRA Administrative Agent to process claims. Coordinate enrollment activity with Plan Sponsor or Named Fiduciary and producer. Timely processing and application of contributions and investment allocation instructions, if applicable. Electronically interface with HRA Administrative Agent, as applicable, for disbursements using secured methods as agreed upon by both parties. • Provide secure Internet access and toll -free telephone service for account inquiries, allocation changes and fund transfers. • Availability of a Customer Service Associate to provide service on account information, fund allocations and distribution request initiation. Daily reconciliation of plan and participant activity. • Perform fund valuations on a daily basis. Quarterly sponsor reports showing fund activity and account balances. Provide quarterly participant statement of activity mailed directly to participant. Plan Sponsor or Plan Sponsor /Named Fiduciary acknowledges that the Plan is not subject to Title I of the Employee Named Fiduciary Retirement Income Security Act (" ERISA ") and that the trust meets the requirements of IRC Sections Authorizations, 501(c)(9) and /or 115. Agreements Plan Sponsor /Named Fiduciary has received materials describing the actual or estimated charges, fees, and Signature discounts, penalties or adjustments currently in effect and which may be applied in connection with the purchase, holding, exchange or termination of the Funding Agreement. • The Plan's selection of investments under the Funding Agreement is based solely upon the printed disclosure material provided by ING. ING is not responsible for the selection or supervision of service providers or any Fiduciaries to the Plan (e.g., investment advisers, record keepers or HRA Administrators). Where a sales representative of ING is also a Service Provider to the Plan, or undertakes a Fiduciary role, he /she is not acting on behalf of ING when providing those services, or when acting in any fiduciary capacity and is not receiving any compensation from ING for such services. Plan Sponsor/Named Fiduciary hereby agrees that if the HRA Administrator is terminated or unable to act for any reason then Plan Sponsor /Named Fiduciary, will be responsible for fulfilling the responsibilities delegated to the HRA Administrator until such time as a replacement HRA Administrator is property designed and assumes such responsibilities. ING's obligations to the Plan are governed solely by the terms of its Funding Agreement, Plan Sponsor Submission Information and ING Trust Agreement, if applicable. Plan Sponsor/Named Fiduciary has read and understands the information described or referred to previously and is authorized to sign these forms on behalf of the Plan. Plan Sponsor/Named Fiduciary hereby provides written direction to ING allowing allocation changes and/or inter -fund transfers to be made by Participants in allocated accounts. Not applicable to unallocated contracts. • Plan Sponsor)Named Fiduciary hereby provides written direction to ING to accept instructions for authorized parties of the HRA Administrative Agent with regard to the processing of claims and withdrawals. Plan Sponsor/Named Fiduciary acknowledges that neither ING, nor anyone acting as its agent, is a party to, or Fiduciary of, the Plan for any purpose, or has any responsibility for any tax or other requirements or consequences to the Plan or to any Participant or Beneficiary of the Plan. I acknowledge that I have consulted my tax or legal advisor regarding the tax and other consequences of the Plan. Plan Sponsor/Named Fiduciary understands that they have selected a funding agreement and that the tax laws provide for exclusion of taxation on earnings on Participants' account balances. Although the funding agreement provides features and benefits that may be of value to Participants, it does not provide any additional tax benefit beyond that provided by the Plan. Plan Sponsor /Named Fiduciary acknowledges that the information they have provided in this form is accurate, and that the fees and compensation disclosed in this form are reasonable. Plan SponsorNamed Fiduciary acknowledges and approves the description of the responsibilities of the various parties outlined in this form. • plan Sponsor /Named Fiduciary agrees to indemnify and hold ING harmless from any preexisting compliance or regulatory issue associated with the Plan including any exposure caused by any outside third party prior to converting to ING. Plan Sponsor /Named Fiduciary has received and read ING's Excessive Trading Policy. Plan Sponsor or Named Fiduciary Name (please type or print) I Tax ID No. Form No. 82362 Non -ERISA Gov HRA (121012005) Page 7 of 9 — Incomplete without all pages Part 4 — Producer, Field Office, & Marketing Information Distribution/ Complete the below Agent and /or Broker information. Producer Agent - includes Career Agent (ING FA Only)-appointed with ING Life Insurance and Annuity Company, registered representative of ING Financial Advisers, LLC. Receive commission based compensation. Broker- (Non ING FA Only) appointed with ING Life Insurance and Annuity Company, but affiliated with a broker dealer other than ING Financial Advisers, LLC. Receive commission based compensation. List names and codes of all Agents and Brokers enrolling and servicing this case. Check off whether the representative is an Agent or Broker. ❑ Agent Representative Name Broker Dealer Affiliation Office Rep. % Last digits of ❑ Broker Code No. Participation SSN N(A ❑ Agent Representative Name Broker Dealer Affiliation Office Rep. % Last dglts of ❑ Broker Code No. participation SSN ❑ Agent Representative Name Broker Dealer filiation Office Rep. % Last 4 digits of ❑ Broker Code No. Participation SSN Agent Representative Name Broker Dealer Afftliaoon Office Rep. % Lad d digit of ❑ Broker Code No. Participation SSN El Agent Represenative Name Broker Dealer Affiliation Office Rep. % Last 4 digit of ❑ Broker Code No. Participation SSN Field Office Sales Manager Name and Title (Please punt) Approval Gavin T. Gruenberg, Major Accounts Specialist Sales Managers Signature Marketing Pro al Date RFP Date Information Consultant Name Telephone No. Form No. 82352 Non -ERISA Gov HRA (1210112005) Page 8 of 9 — Incomplete without all pages Part 5 — Domestic Emerging Markets INFORMATION Domestic Emerging Markets * iNG o'efines Domestic Emerging Markets as those high growth segments of the United States population that control a large and ever - increasing segment of the economy. To help us better serve our Plan Sponsors and their Participants, please tell us about the demographics of this new case. This information will help ING provide our customers with specialized capabilities and services, e.g., bilingual capabilities, the Calendar of African American History, and /or brochures and books to help women meet their special financial needs. The information, if provided, will be confidential except when used to direct these and other ING resources. Thank you Are any of the following Domestic Emerging Markets significantly represented in the Employee population (i.e., 20% of the Employee population or greater): Yes No Unknown If Yes African American ❑ ❑ ❑ _ % if known Asian American ❑ ❑ ❑ _ °% if known Latino /Hispanic ❑ ❑ ❑ _ °% if known Other Emerging Market ❑ ❑ ❑ _ % if known Please specify _ Complete the following based on the demographics of the person(s) who are the decision makers for the purchase of ING's program /service. ❑ woman ❑ African American ❑ Asian American ❑ Latino/Hispanic ❑ Other Emerging Market — Please Specify: ❑ None of the above Form No, 62362 Non -ERISA Gov HRA (72/07 /2005) Page 9 of 9 — Incomplete without all pages