Voya Fixed Annuities Fixed Annuity Application

Transcription

1 Voya Fixed Annuities Fixed Annuity Application Countrywide except AK, AZ, CT and VA Issued by Voya Insurance and Annuity Company RETIREMENT INVESTMENTS INSURANCE

2 IMPORTANT INFORMATION AND REMINDERS Page 1 Only one product is selected per application. Complete a separate application for each additional product to be purchased. If SPIA, a Single Premium Immediate Annuity Payout Choices Request must be completed (attached at the back of this form for your convenience). New Jersey residents must complete form in replace of the Single Premium Immediate Annuity Payout Choices Request and summit with application. Applicable strategy allocations total 100%. Page 2 The name, address, date of birth and Social Security number/tax identifi cation number are provided for each individual/entity named. For non-natural owners, documentation is included (Certifi cate of Trust form, corporate resolution, power of attorney paperwork, etc.) confi rming the person is allowed to act on behalf of the owner. Remember to include the signature page with the documentation. Page 3 The primary or contingent status for each named benefi ciary is selected in section 4. Each benefi ciary is named individually. If there are any trust designations, the trust name is included. Designated benefi ciary (primary and contingent) percentages are clearly entered and each benefi ciary type (primary and contingent) totals 100%. The initial premium meets the product s minimum requirements. The tax type for this new annuity (i.e., Non-qualifi ed, IRA, SIMPLE IRA) is indicated in section 5, and any applicable conversion/ establishment dates are provided. If the transfer involves a non-qualifi ed annuity or life insurance policy and is like to like, 1035 Exchange is selected. If a transfer is required, the approximate transfer amount is entered in section 5. If a replacement is involved, the appropriate transfer and state replacement forms are complete and submitted with this form. If the Voya Joint IncomeProtector Withdrawal Benefi t is selected on a custodially owned contract, the custodial benefi ciary information is entered in section 4. Page 5 If there are additional beneficiaries, please make sure they are clearly entered in section 7 - Speical Remarks - or on a separate piece of paper signed and dated by the owner. The owner signed and dated section 7. Be sure to include the city and state where this application is signed. If this form is signed by a power of attorney, legal guardian, etc., a copy of the appropriate supporting documentation is provided confi rming the signer s ability to act on behalf of the owner. The owner enclosed the check or 1035/transfer paperwork. The correct product disclosure, which explains specifi c product information such as surrender charges, partial withdrawals and MVA provision (if applicable), was provided and read to the applicant. The disclosure also has applicant and producer signatures. Page 6 The name, National Producer Number, Social Security number, phone number and signature for the producer are provided. If more than one producer is listed, the producer commission split is entered and totals 100%. Copies of all presented sales materials were left with applicant for future reference. Single Premium Immediate Annuity (SPIA) Information The Single Premium Immediate Annuity information is completed (if applicable). If the Life Income Only payout option is selected, owner(s) have also initialed under the disclaimer. Automatic Programs Request Bank information is verifi ed. If EFT or Direct Deposit option is selected, a voided check is submitted with the application. MAILING INSTRUCTIONS Send completed and signed documents to: Regular Mail: Voya Fixed Annuities Customer Service: Voya Fixed Annuities Attn: New Business Attn: New Business PO Box Locust Street Des Moines, IA Des Moines, IA Questions? Call: Licensing Department: Customer Service: Sales Desk:

3 Voya IncomeProtector Withdrawal Benefit and Voya Joint IncomeProtector Withdrawal Benefit There are certain requirements that must be met at the time of issue to successfully elect the Voya IncomeProtector Withdrawal Benefi t or Voya Joint IncomeProtector Withdrawal Benefi t. Applications that do not comply with these issue requirements will be deemed not in good order, and the contract will not be issued. In order to elect the Voya IncomeProtector Withdrawal Benefi t or Voya Joint IncomeProtector Withdrawal Benefi t, the annuitant must be either the owner or joint owner of the contract. A joint annuitant is only permitted if Voya Joint IncomeProtector Withdrawal Benefi t is selected under a non-qualifi ed plan and the annuitant and joint annuitant are spouses. For single premium contracts, eligible premiums include any premium and any bonus received on the contract date. For fl exible premium contracts, eligible premiums include any premiums and bonus received in the growth/deferral phase. For further details please refer to the rider disclosure. The Voya Joint IncomeProtector Withdrawal Benefi t can only be issued if there are two individuals who are married at the time of issue (a spouse or the spouses ) and meet the ownership, annuitant and benefi ciary issue requirements listed in the table below. Please consult your fi nancial advisor to determine whether you meet the requirements. Voya Joint IncomeProtector Withdrawal Benefit Issue Requirements Type of Plan Owner 1 Ownership Requirements Annuitant(s) Requirements Primary Benefi ciary Requirements Non-Qualifi ed Joint owners The two owners must be the Must be a spouse None two spouses. Single owner The owner must be a spouse. Must be a spouse Sole primary benefi ciary must be owner s spouse Qualifi ed-ira Single owner 2 The owner must be a spouse. Must be the owner Sole primary benefi ciary must be owner s spouse 3 1 Non-natural owners are not allowed. Neither joint owners nor non-natural owners are allowed under qualifi ed plans. 2 Includes custodial accounts. The benefi cial owner of the custodial account must be one of the spouses. 3 If a custodial account, this requirement applies to the benefi ciary information on record with the custodian. Changes in ownership, annuitant and/or benefi ciary designations, and changes in marital status may affect the terms and conditions of the Voya Joint IncomeProtector Withdrawal Benefi t. Please refer to your rider and disclosure statement for details to determine if this living benefi t option is consistent with your needs and objectives in purchasing an annuity contract. If you decide to elect the Voya Joint IncomeProtector Withdrawal Benefi t, please be sure to provide names, birth dates and Social Security numbers wherever requested on the application. Please follow the instructions listed on the Important Information and Reminders page at the beginning of this document. SAMPLE BENEFICIARY DESIGNATIONS Be sure to use given names such as Mary M. Doe, not Mrs. John Doe, and include the address and relationship of the beneficiary or beneficiaries to the owner. The following designations may be helpful to you: Name Relationship to Owner Birth Date SSN/TIN Percent One Primary Benefi ciary Mary M. Doe Sister 03/31/ % Two Primary Benefi ciaries Jane J. Doe John J. Doe Mother Father 04/01/ /01/ % 50% One Primary Benefi ciary One Contingent Jane J. Doe John J. Doe Wife Son 11/30/ /18/ % 100% Estate Estate of John Doe Estate N/A % Trust Testamentary Trust 4 (Trust established within the owner s will) ABC Trust Dated 1/1/85 Trust created by the Last Will and Testament of John Doe Trust N/A % Testamentary Trust N/A % 4 If the trust is terminated or if no trustee is qualified to receive the proceeds within six months of the insured s death, then the proceeds go to the owner or owner s estate.

4 APPLICATION Voya Insurance and Annuity Company (the Company ) A member of the Voya family of companies Fax: Mail: PO Box 1337, Des Moines, IA Customer Service: 909 Locust Street, Des Moines, IA Website: Voya.com Phone: (A). PRODUCT SELECTION (Must select one. All products or strategies may not be available in all states.) Flexible Premium Products Secure Index Five Fixed Index Deferred Annuity Initial Premium Election (Use whole percentages only): Fixed Rate Strategy Point-to-Point Cap Index Strategy Monthly Average Index Strategy Monthly Cap Index Strategy Performance Trigger Index Strategy Point-to-Point Volatility Control Strategy Total 100% Secure Index Seven Fixed Index Deferred Annuity Initial Premium Election (Use whole percentages only): Fixed Rate Strategy Point-to-Point Cap Index Strategy Monthly Average Index Strategy Monthly Cap Index Strategy Performance Trigger Index Strategy Point-to-Point Volatility Control Strategy Total 100% Guarantee Choice Deferred Annuity Single Premium Products Secure Index Opportunities Plus Fixed Index Deferred Annuity Initial Premium Election (Use whole percentages only): Fixed Rate Strategy Point-to-Point Cap Index Strategy Monthly Average Index Strategy Monthly Cap Index Strategy Performance Trigger Index Strategy Point-to-Point Volatility Control Strategy Total 100% Secure Index Outlook Fixed Index Deferred Annuity Initial Premium Election (Use whole percentages only): Fixed Rate Strategy Point-to-Point Cap Index Strategy Monthly Average Index Strategy Monthly Cap Index Strategy Performance Trigger Index Strategy Point-to-Point Volatility Control Strategy Total 100% X Single Premium Immediate Annuity (Please complete Single Premium Immediate Annuity Payout Choices Request and submit with application. New Jersey residents must complete form in place of the Single Premium Immediate Annuity Payout Choices Request.) 1(B). OPTIONAL RIDER SELECTION (Only one option is available.) Enhanced Death Benefit Rider (Check with Voya Annuity and Asset Sales for availability.) Voya SMARTLEGACY DEATH BENEFIT (The Voya SmartLegacy Death Benefit is an enhanced death benefit that guarantees that the death benefit payout of your contract will be equal to the premium(s) paid increased at a specific percentage up to a maximum amount, adjusted for partial surrenders. See rider disclosure for more information.) Minimum Guaranteed Withdrawal Benefit Rider PLEASE SUBMIT THE RIDER DISCLOSURE FORM WHEN SELECTING EITHER OF THE TWO OPTIONS IN THIS SECTION. (Select no more than one.) Voya INCOMEPROTECTOR MINIMUM GUARANTEED WITHDRAWAL BENEFIT (See previous page and rider disclosure for more information.) Voya JOINT INCOMEPROTECTOR MINIMUM GUARANTEED WITHDRAWAL BENEFIT (There are specific ownership and beneficiary requirements for selection of the Voya Joint IncomeProtector Withdrawal Benefit. See previous page and rider disclosure for more information.) Voya RETURN OF PREMIUM RIDER (Not available with any other rider selection and only available with Secure Index Five.) (The Return of Premium rider provides a guarantee that, upon full Surrender, the Contract s Cash Surrender Value will never be less than the sum of all premium(s) paid, minus any prior net withdrawals and any applicable Premium Taxes withheld. See Secure Index Five disclosure for more information.) (06/14) Page 1 of 6 - Incomplete without all pages. Order # /07/2015

5 2. OWNER (If a trust is designated as the owner, complete the Certificate of Trust form and submit it with this application.) Name SSN/TIN Birth Date/Trust Date Marital Status (Select one): Married Single Widow/Widower Male Female Street Address (PO boxes are not permitted.) City State ZIP Mailing Address (If different than above.) City State ZIP Country of Citizenship Country of Incorporation Phone Address JOINT OWNER (Not available with qualified plans or if selecting the enhanced death benefit.) Name SSN Birth Date Marital Status (Select one): Married Single Widow/Widower Male Female Street Address (PO boxes are not permitted.) City State ZIP Mailing Address (If different than above.) City State ZIP Country of Citizenship Relationship to Owner Phone Address 3. ANNUITANT(S) (Designate an annuitant below in the event that: 1) the individual owner is not the annuitant; 2) there is joint ownership; or 3) the owner is not an individual. If an individual owner is named and an annuitant is not named below, the individual owner will be named as the annuitant. The owner is required to have an insurable interest in the life of the annuitant. An insurable interest is defined as the owner has a lawful and substantial economic interest in the continued life of the annuitant.) Name Phone SSN Street Address (PO boxes are not permitted.) Birth Date Male Female City State ZIP Country of Citizenship Relationship to Owner JOINT ANNUITANT (Only applicable for non-qualified plans, and if electing the Voya Joint IncomeProtector Withdrawal Benefit. A joint annuitant is not permitted if the owner is not an individual and the enhanced death benefit is elected. If there is a joint owner named and the annuitant is not named, the joint owner will be named as the joint annuitant.) Name Phone SSN Street Address (PO boxes are not permitted.) Birth Date Male Female City State ZIP Country of Citizenship Relationship to Owner Contingent annuitant (Provide the contingent annuitant s name, SSN, birth date, gender, and street address in the Special Remarks area of Section 7.) (06/14) Page 2 of 6 - Incomplete without all pages. Order # /07/2015

6 4. BENEFICIARY INFORMATION If you would like to designate a restricted beneficiary, complete the Restricted Beneficiary form and submit it with this application. Total percentage of primary beneficiary shares must equal 100%. Total percentage of contingent beneficiary shares must also equal 100%. If no percentages are listed, beneficiaries' shares will be distributed equally. Additional beneficiaries should be listed on a separate piece of paper that includes the owner s signature and the date. Name Gender Birth Date/Trust Date SSN/TIN % Address Phone Relationship to Owner Beneficiary Type: Primary Name Gender Birth Date/Trust Date SSN/TIN % Address Phone Relationship to Owner Name Gender Birth Date/Trust Date SSN/TIN % Address Phone Relationship to Owner Name Gender Birth Date/Trust Date SSN/TIN % Address Phone Relationship to Owner Beneficiary Type: Primary Contingent Beneficiary Type: Primary Contingent Beneficiary Type: Primary Contingent CUSTODIAL BENEFICIARY (Required only if Voya Joint IncomeProtector Withdrawal Benefit is selected on a custodially owned contract. This sole primary beneficiary must be the spouse of the annuitant. All fields must be completed.) Name Birth Date Percent 100 % SSN/TIN Is this sole beneficiary the spouse of the annuitant? Yes No Address Phone 5. PREMIUM AND PLAN TYPE Make all checks payable to Voya Insurance and Annuity Company. Complete either the nonqualified or the qualified section, not both. Premium: $ and/or Estimated Amount of Transfer(s)/1035 Exchange(s): $ NONQUALIFIED - SOURCE OF FUNDS: New Purchase (money with application) 1035 Exchange Transfer from money market account, CD or mutual fund QUALIFIED - SOURCE OF FUNDS: New Purchase (money with application) Contribution for tax year Rollover Transfer Qualified Type Applied For: Traditional IRA Roth IRA SEP-IRA SIMPLE IRA Qualifi ed Other (06/14) Page 3 of 6 - Incomplete without all pages. Order # /07/2015

7 6. IMPORTANT INFORMATION AND STATE REQUIRED NOTICES To help the government fi ght the funding for terrorism and money-laundering activities, federal law requires all fi nancial institutions to obtain, verify, and record information that identifi es each person who opens an account. What this means for you when you apply for an annuity, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver s license or other identifying documents. If you wish to have a more detailed explanation of our information practices, please write to: Customer Service, Voya Annuities, 909 Locust Street, Des Moines, IA Below are notices that apply only in certain states. Please read the following carefully to see if any apply in your state. Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. Arkansas, Louisiana, Ohio, Oklahoma, Tennessee, West Virginia: Any person who knowingly and with intent to injure, defraud or deceive any insurance company, submits an application for insurance containing any materially false, incomplete, or misleading information, or conceals for the purpose of misleading, any material fact, is guilty of insurance fraud, which is a crime and in certain states, a felony. Penalties may include imprisonment, fi ne, denial of benefi ts, or civil damages. California Reg 789.8: The sale or liquidation of any stock, bond, IRA, certifi cate of deposit, mutual fund, annuity, or other asset to fund the purchase of this product may have tax consequences, early withdrawal penalties, or other costs or penalties as a result of the sale or liquidation. You or your agent may wish to consult independent legal or fi nancial advice before selling or liquidating any assets and prior to the purchase of any life or annuity products being solicited, offered for sale, or sold. Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the applicant. Florida: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Illinois Civil Union Notice: Effective June 1, 2011, for contracts issued in Illinois, the Company is in compliance with the Illinois Religious Freedom Protection and Civil Union Act (Public Act ) to the extent allowed under Federal Law. Illinois Public Act ( the Act ) provides that civil union couples, as defi ned in the Act, are entitled to the same legal obligations, responsibilities, protections and benefi ts that are afforded or recognized by the laws of Illinois to spouses in a marriage. Under Federal Law, however, certain favorable federal tax treatment available to spouses that are married is not available to partners in a civil union, e.g. spousal continuation. If you are a civil union partner, we suggest that you consult with a tax advisor prior to purchasing an annuity contract, such as this one, which provides spousal benefi ts. Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. 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. New Mexico: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or 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 fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Maine, Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. Rhode Island: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison (06/14) Page 4 of 6 - Incomplete without all pages. Order # /07/2015

8 7. ACKNOWLEDGEMENTS AND SIGNATURES (Please read carefully.) SIGNATURE REQUIRED BELOW! THIS ENTIRE SECTION MUST BE COMPLETED FOR YOUR APPLICATION TO BE PROCESSED IN GOOD ORDER. REPLACEMENT If either question below is answered Yes, you must complete any state-required replacement forms, as applicable, and submit them with this application. 1. Do you currently have any existing individual life insurance policies or annuity contracts? (If Yes, complete the state-required replacement form(s) and provide details below.) Yes No 2. Will this contract replace any existing individual life insurance policies or annuity contracts? (If Yes, complete the state-required replacement form(s) and provide details below.) Yes No Company Policy/Contract # Company Policy/Contract # SPECIAL REMARKS The annuity applied for does not take effect until Voya Insurance and Annuity Company receives the purchase payment. Make checks payable ONLY to Voya Insurance and Annuity Company. Do not make checks payable to the producer, an agency or another company. Only the President, Vice President or Secretary of Voya Insurance and Annuity Company may modify, discharge or waive any of its rights under the contract. I agree that, to the best of my knowledge and belief, all statements and answers in this application are complete and true. I understand that the statements and answers may be relied upon by Voya Insurance and Annuity Company in deciding whether to issue the contract. I have been advised that: 1) the value allocated to any account subject to a market value adjustment may increase or decrease if surrendered or withdrawn prior to a specified date(s) as stated in the contract. 2) if the annuity applied for offers an equity index strategy or interest rate benchmark strategy, contract values may be affected by an external index or interest rate benchmark. The contract does not directly participate in any stock, bond or equity investments. Any values shown, other than guaranteed minimum values, are not guarantees, promises or warranties. 3) cash values under a flexible premium annuity where one premium is paid may be lower than cash values under a single premium annuity, and that purchase of a flexible premium annuity may be inappropriate in such case. I have reviewed a copy of any disclosure material that applies to this contract. I have also received an original or a copy of any written, printed, or electronic communications used to present this product. I understand there is a penalty for early surrender of the annuity. U.S. TAXPAYER CERTIFICATIONS Under penalties of perjury, I certify that: 1. The Taxpayer Identification Number that appears on this form is correct. 2. I am not subject to back-up withholding due to failure to report interest and dividend income; If I am subject to backup withholding, I have checked here.; and 3. I am a U.S. person. If you are a Non-Resident Alien, please check the box below. Under penalties of perjury, I certify that I am a Non-Resident Alien. The amount paid to you will be subject to 30% tax withholding unless you submit an IRS Form W-8 and are entitled to claim a reduced rate of withholding under the applicable U.S. tax treaty. The Internal Revenue Service does not require your consent to any provision of this document other than the certifications (in bold above) required to avoid back-up withholding. Owner Signature Signed at (city, state) CA Date Signed at (city, state) Joint Owner Signature (if applicable) By signing below, I consent to being the individual annuitant. Annuitant Signature (if other than named owner(s)) Annuitant Signature (if other than named owner(s)) (06/14) Page 5 of 6 - Incomplete without all pages. Order # /07/2015 Date Date Date

9 8. PRODUCER INFORMATION CHECK THE BOXES BELOW ONLY IF THEY APPLY: Check here to confirm that the owner(s) has an insurable interest in the life of the annuitant. Insurable interest means the owner has a lawful and substantial economic interest in the continued life of the annuitant. Check here if the applicant is on active duty with the U.S. Armed Forces or is a dependent of any active duty service member of the U.S. Armed Forces. Complete the Military Personnel Financial Services Disclosure Regarding Insurance Products and return it with this application. If any questions below or in the Replacement section are answered Yes, the applicant must complete and submit any staterequired replacement forms/sales material, as applicable, with this application. Does the applicant have any existing individual life insurance policies or annuity contracts? Yes No Do you have reason to believe that the contract applied for will replace any existing annuity or life insurance coverage?.. Yes No If your state has adopted replacement regulations, did you remember to do the following? Provide required replacement notice to the applicant and offer to read it aloud. Complete required, state-specific paperwork. Compensation Alternative (Select one. If no choice is made, Option A will be the default. Please verify which options are available.) Option A Option B - Trail Option C - Trail Option D - Trail Compensation will be split equally if no percentage is indicated. Partial percentages will be rounded up. Percentages must total 100%. The primary producer will be given the highest percentage in the case of unequal percentages and will receive all correspondence regarding the contract. By signing below you certify that: 1) replacement questions were answered; 2) any sales material was shown to the applicant and a copy was left with the applicant; 3) you used only insurer-approved sales material; 4) you have not made statements that differ from the sales material; 5) you have truly and accurately recorded on the application the information provided by the applicant; and 6) no promises were made about the future value of any contract elements that are not guaranteed. (This includes any expected future gains that may apply to this contract.) SIGNATURE REQUIRED BELOW! THIS ENTIRE SECTION MUST BE COMPLETED FOR YOUR APPLICATION TO BE PROCESSED IN GOOD ORDER. Primary Producer: Split % Print Name SSN/NPN ******** MICHELLE TWANO Signature License # (FL Producers only) Address City State ZIP Phone Marketing Organization Address Marketing Organization Phone Strategic Distribution Producer Only - If issuing this business through your strategic contract, please complete the following: Strategic WAP Strategic NAC Managing Director Producer #2: Split % Print Name SSN/NPN Signature License # (FL Producers only) Strategic Distribution Producer Only - If issuing this business through your strategic contract, please complete the following: Strategic WAP Strategic NAC Managing Director Producer #3: Split % Print Name SSN/NPN Signature License # (FL Producers only) Strategic Distribution Producer Only - If issuing this business through your strategic contract, please complete the following: Strategic WAP Strategic NAC Managing Director (06/14) Page 6 of 6 - Incomplete without all pages. Order # /07/2015

10 SINGLE PREMIUM IMMEDIATE ANNUITY (SPIA) PAYOUT CHOICES REQUEST Voya Insurance and Annuity Company A member of the Voya family of companies Fax: Mail: PO Box 1337, Des Moines, IA Customer Service: 909 Locust Street, Des Moines, IA Website: Voya.com Phone: Fixed Annuities After the contract s right to examine or cancel period has expired, your contract will not have a surrender value. This means that during the annuitant s or joint annuitant s lifetime you will not be able to get your purchase payment money back. Your purchase payment money will be paid out as a stream of payments while the annuitant or joint annuitant is living, if applicable, over the period of time selected by you. Owner Name Joint Owner Name SSN SSN 1. ANNUITY OPTIONS For annuity options B - K below, satisfactory evidence of date of birth of the Annuitant(s), must also be provided. Driver s license, passport, or birth certificate are the only documents accepted as proof of age. If you would like your payments deposited directly into your bank account, please complete the Bank Account Information section on the Automatic Programs Request. Guarantee periods cannot extend beyond age 105 for non-qualifi ed contracts or the earlier of age 100 and life expectancy for qualifi ed contracts. SELECT ONE ANNUITY OPTION BELOW. (Select one option only, then select no more than one of the Optional Features.) Non-Lifetime Option A. Period Certain (Select one period.) 5 years 10 years 15 years 20 years 25 years 30 years Other Single Lifetime Options B. Single Life Only C. Single Life with Period Certain (Select one period.) 5 years 10 years 15 years 20 years Other Joint Lifetime Options D. Joint Life & 100% Survivor E. Joint Life & 100% Survivor with Period Certain (Select one period.) 5 years 10 years 15 years 20 years Other F. Joint Life & 75% Survivor (Not available if increasing annuity is selected.) G. Joint Life & 66 ⅔% Survivor (Not available if increasing annuity is selected.) H. Joint Life & 50% Survivor (Not available if increasing annuity is selected.) I. Joint Life & 75% Contingent Survivor (Not available if increasing annuity is selected.) J. Joint Life & 66 ⅔% Contingent Survivor (Not available if increasing annuity is selected.) K. Joint Life & 50% Contingent Survivor (Not available if increasing annuity is selected.) Life Income Only (All owners must also initial the disclaimer below, if any of the following annuity options were selected above - options B, D, F, G, H, I, J, or K - and you did not choose a Cash Refund or Installment Refund.) Disclaimer: You have elected a Life Income Only option which means that payments will be made during the life of the annuitant. After the annuitant s death, no further payments will be made. If this is a Joint Life Income Only option, after the last annuitant s death, no further payments will be made. No payments will be made to the annuitant s estate or to any other person. No Benefi ciaries may be designated. Owner Initials Joint Owner Initials Optional Features (Select one only.) No Optional Payout Feature (This is the default if no selection is made.) 3% Increasing Annuity (Available with options A, B, C, D, and E.) 6% Increasing Annuity (Available with option A.) Cash Refund at Annuitant s Death (Available with option B.) Installment Refund at Annuitant s Death (Available with option B.) Order # /07/2015

11 2. JOINT LIFE INFORMATION (Complete if you selected a Joint Lifetime option in section 1.) Name SSN Birth Date Street Address (PO boxes are not permitted.) City State ZIP 3. FREQUENCY OF PAYMENT (Select a payment period.) Monthly Quarterly Semi-Annually Annually 4. INCOME START DATE The Owner has 30 days from date of receipt to examine the SPIA contract. No payouts will be made during this time. The Income Start Date will be one payment period from the contract issue date. If a different date is indicated below it must be between the 1st - 28th of the month. If the Income Start Date will result in less than an entire payment period, the payout amount will be adjusted accordingly. Example: Application received on 1/1/2011. Premium received on 1/20/2011. Contract issued 1/21/2011. First payout cannot be prior to 2/20/2011. Earliest Date Available OR Day of the Month you would like your payment (Must be the 1st through the 28th) 5. TAX WITHHOLDING ELECTION Regardless of whether or not federal or state income tax is withheld, you are liable for taxes on the taxable portion of the payment. If you do not have a sufficient amount withheld, you may be subject to tax penalties under the Estimated Tax Payment rules. An election made for a single non-recurring distribution applies only to the payment for which it is being made. For recurring payments, your withholding election will remain in effect until it is changed or revoked. You may change or revoke your election at any time prior to a payment being made by submitting IRS form W-4P. Non-periodic payments 10% withholding: Non-periodic, non-rollover eligible payments from pensions, annuities, IRA s and life insurance contracts are subject to a flat 10% federal withholding rate unless you choose not to have federal income tax withheld. These include for example, required minimum distributions, hardship withdrawals, and distributions from IRA s that are payable on demand. You can choose not to have withholding applied to your non-periodic distribution by checking the applicable box below. You may also elect withholding in excess of the flat 10% rate. Periodic payments: Withholding from periodic payments of a pension or annuity that are not rollover eligible is figured in the same manner as withholding from wages. Periodic payments are made in installments at regular intervals over a period of more than 1 year. You may elect out of withholding. If you do not elect out, withholding from your periodic payment will be based on the marital status and withholding allowances you specify below. You may also elect an additional amount to be withheld from your payment. If you do not make an election, withholding will occur at a rate equal to an election of Married with 3 withholding allowances. FEDERAL WITHHOLDING INSTRUCTIONS: DO NOT withhold any federal income tax unless mandated by law. DO withhold federal taxes (20% is mandated for eligible rollover distributions.) Marital Status: Single Married Married, but withhold at higher Single rate Total number of Allowances: ADDITIONAL AMOUNT you want withheld from your payment(s) $ or %. (Note: This amount is in addition to the standard federal withholding rate applicable to your distribution.) Notices: U.S. persons having their payment delivered outside the U.S. or its possessions may not make an election of NO withholding. In this case, if you choose no withholding, the default rate will be applied. Non-resident aliens are subject to a mandatory 30% withholding rate unless they are eligible for a reduced rate or exemption under a tax treaty and the required documentation is submitted. STATE WITHHOLDING INSTRUCTIONS: My residence state for tax purposes is (If your current physical and/or mailing address is outside of your state of legal residence for tax purposes, please enter your tax state here. If no U.S. state or territory is on record and one is not specified, we will presume this income is not reportable to any U.S. state or territory.) DO NOT withhold any state income tax unless mandated by law. DO withhold state taxes in the amount of $ or %. (If you make this election, a dollar amount or percentage must be specified and cannot be less than any required withholding.) If you do not make an election or if your state requires a greater amount of withholding, we will withhold at the rate specified by your state of residence for the type of payment you are receiving. In some cases, your state specific withholding election form is required to opt out of withholding or to choose a rate other than the state s default rate. Refer to the attached State Income Tax Withholding Notification and/or your State Department of Taxation for details. 6. AUTHORIZATION Owner Signature Date Joint Owner Signature (If applicable) Date Order # /07/2015

12 AUTOMATIC PROGRAMS REQUEST Voya Insurance and Annuity Company (the Company ) A member of the Voya family of companies Fax: Mail: PO Box 1337, Des Moines, IA Customer Service: 909 Locust Street, Des Moines, IA Website: Voya.com Phone: Fixed Annuities Owner Name Joint Owner Name SSN SSN OPTIONAL SYSTEMATIC PARTIAL WITHDRAWALS (Select one.) You must wait 30 days from the date the contract is issued before requesting withdrawals. To have withdrawals from your annuity contract deposited into your bank account, please complete the Bank Account Information Section below. Maximum amount available without surrender charges/market value adjustment (This option may affect any future rider guarantees.) Specifi ed Payment $ ($25.00 Minimum) Specifi ed Percentage Maximum Annual Withdrawal (MAW) under the Voya IncomeProtector Withdrawal Benefit or Voya Joint IncomeProtector Withdrawal Benefit, (This option is only available on contracts with the Voya IncomeProtector or Voya Joint IncomeProtector rider. Please refer to your rider and disclosure statement for details.) Frequency Monthly Quarterly Semi-Annually Annually Starting (any day through the 28th) (MM/DD/YYYY) TAX WITHHOLDING ELECTION Regardless of whether or not federal or state income tax is withheld, you are liable for taxes on the taxable portion of the payment. If you do not have a sufficient amount withheld, you may be subject to tax penalties under the Estimated Tax Payment rules. An election made for a single non-recurring distribution applies only to the payment for which it is being made. For recurring payments, your withholding election will remain in effect until it is changed or revoked. You may change or revoke your election at any time prior to a payment being made by submitting IRS form W-4P. Non-periodic payments 10% withholding: Non-periodic, non-rollover eligible payments from pensions, annuities, IRA s and life insurance contracts are subject to a flat 10% federal withholding rate unless you choose not to have federal income tax withheld. These include for example, required minimum distributions, hardship withdrawals, and distributions from IRA s that are payable on demand. You can choose not to have withholding applied to your non-periodic distribution by checking the applicable box below. You may also elect withholding in excess of the flat 10% rate. Periodic payments: Withholding from periodic payments of a pension or annuity that are not rollover eligible is figured in the same manner as withholding from wages. Periodic payments are made in installments at regular intervals over a period of more than 1 year. You may elect out of withholding. If you do not elect out, withholding from your periodic payment will be based on the marital status and withholding allowances you specify below. You may also elect an additional amount to be withheld from your payment. If you do not make an election, withholding will occur at a rate equal to an election of Married with 3 withholding allowances. Order # /07/2015

13 TAX WITHHOLDING ELECTION (CONTINUED) FEDERAL WITHHOLDING INSTRUCTIONS: DO NOT withhold any federal income tax unless mandated by law. DO withhold federal taxes (20% is mandated for eligible rollover distributions.) Marital Status: Single Married Married, but withhold at higher Single rate Total number of Allowances: ADDITIONAL AMOUNT you want withheld from your payment(s) $ or %. (Note: This amount is in addition to the standard federal withholding rate applicable to your distribution.) Notices: U.S. persons having their payment delivered outside the U.S. or its possessions may not make an election of NO withholding. In this case, if you choose no withholding, the default rate will be applied. Non-resident aliens are subject to a mandatory 30% withholding rate unless they are eligible for a reduced rate or exemption under a tax treaty and the required documentation is submitted. STATE WITHHOLDING INSTRUCTIONS: My residence state for tax purposes is (If your current physical and/or mailing address is outside of your state of legal residence for tax purposes, please enter your tax state here. If no U.S. state or territory is on record and one is not specified, we will presume this income is not reportable to any U.S. state or territory.) DO NOT withhold any state income tax unless mandated by law. DO withhold state taxes in the amount of $ or %. (If you make this election, a dollar amount or percentage must be specified and cannot be less than any required withholding.) If you do not make an election or if your state requires a greater amount of withholding, we will withhold at the rate specified by your state of residence for the type of payment you are receiving. In some cases, your state specific withholding election form is required to opt out of withholding or to choose a rate other than the state s default rate. Refer to the attached State Income Tax Withholding Notification and/or your State Department of Taxation for details. OPTIONAL PREAUTHORIZED ELECTRONIC FUNDS TRANSFER (EFT) PAYMENT PLAN (Complete bank account information below.) To have Voya Insurance and Annuity Company withdraw payments from your bank account and deposit them into your annuity contract, please complete the Bank Account Information Section below. I understand that all payments made will be allocated pro rata according to the initial allocations entered on this form. I understand and agree to indemnify Voya Insurance and Annuity Company for any costs incurred if there are insuffi cient funds in the account listed below. Deduction Frequency Monthly Quarterly Semi-Annually Annually Amount Date to Start Transfer (MM/DD/YYYY) BANK ACCOUNT INFORMATION (Your initial payment will be mailed to the address of record. Subsequent payments will be deposited directly into your account upon completion of the information below or unless direct deposit is already established.) You authorize us to initiate debit/credit entry(ies) to the account indicated below (a voided check is attached) and in the amount and frequency listed above. This authorization shall remain in force until you give us written notice of termination of this authorization and sufficient time to process. We cannot establish direct deposit to pooled money markets or brokerage accounts. Bank Account Owner Name Joint Owner Name (if applicable) Bank Name Bank Routing/ABA # Bank Phone Bank Address City State ZIP Bank Account # Bank Account Type Checking Savings AUTHORIZATION Owner Signature Date Joint Owner Signature (If applicable) Date Order # /07/2015

14 STATE INCOME TAX WITHHOLDING NOTIFICATION NOTIFICATION If you are a resident of Arkansas, California, Delaware, District of Columbia 4, Georgia 1, Iowa, Kansas, Maine, Maryland 1, Massachusetts, Michigan, Nebraska 2, North Carolina 3, Oklahoma, Oregon, Vermont, or Virginia 1, your state requires state income tax withholding on the taxable portion of your distribution from your 401, 403(b), 408 (IRA), Governmental 457 Plan or Non- Qualified annuity. This state income tax withholding is in addition to the mandatory 20% (or, in some cases, 10%) federal income tax withholding. Please note, when a state cost basis differs from federal, the federal cost basis will be used in determining taxability for state income tax withholding purposes. California or Oregon state income tax withholding will be calculated unless you complete the state withholding section of your Withdrawal Request indicating your election out of state income tax withholding. Arkansas, North Carolina 3 or Vermont, state withholding will be automatically calculated when federal income tax withholding applies. If you do not elect out of 10% federal income tax withholding, you can still choose to elect out of state withholding. Requesting North Carolina withholding over mandatory amounts requires their Form NC-4P, Withholding Certificate for Pension or Annuity Payments. Iowa, Maine, Massachusetts, Nebraska 2, or Oklahoma, state income tax withholding will be automatically calculated as these states do not allow an election out of state income tax withholding when federal income tax withholding applies. Delaware, Kansas or Maryland 1 and are subject to mandatory 20% federal income tax withholding, state income tax withholding will be automatically calculated. State withholding is not required when 10% federal income tax withholding applies. Virginia 1 or Michigan, state income tax withholding will be calculated automatically unless you meet certain criteria and claim an exemption from withholding. To claim an exemption, complete Form VA-4P for Virginia or Form MI-4P for Michigan, and return the appropriate form to us with, and to the same designated location as, your Withdrawal Request. District of Columbia 4 and are receiving a total distribution of your account balance, state income tax withholding will be automatically calculated. State withholding is not required for partial distributions. Georgia 1 and are receiving periodic payments, state income tax withholding will be automatically calculated unless you elect out. 1 Maryland, Virginia and Georgia state income tax withholding is not required for distributions from 408 Plans. 2 Nebraska state income tax withholding is not required for premature distributions from 408 Plans. 3 North Carolina does not apply to distributions from NC state and local government or federal retirement systems for those vested as of 8/12/89. 4 District of Columbia withholding provision is an emergency law that is set to expire on 01/11/13. Important: State tax withholding rules can change, and the rules cited above may not reflect current state legislative requirements. Please consult with a tax or investment advisor to obtain the most up-to-date information. Page 1 of 1 Order # /01/2014

15 NOTICE REGARDING REPLACEMENT REPLACING YOUR LIFE INSURANCE POLICY OR ANNUITY? Voya Insurance and Annuity Company A member of the Voya TM family of companies Customer Service: 909 Locust Street, Des Moines, IA This document must be signed by the applicant and the producer and a copy left with the applicant. Applicant Questions: 1. Do you currently have any existing individual life insurance policies or annuity contracts?... Yes No 2. Will this contract replace any existing individual life insurance policies or annuity contracts?... Yes No Producer Questions: 1. Does the applicant have any existing individual life insurance policies or annuity contracts?... Yes No 2. Do you have a reason to believe that the contract applied for is or may replace any existing annuity or life insurance coverage?... Yes No Are you thinking about buying a new life insurance policy or annuity and discontinuing or changing an existing one? If you are, your decision could be a good one or a mistake. You will not know for sure unless you make a careful comparison of your existing benefits and the proposed benefits. Make sure you understand the facts. You should ask for the advice of the company or agent that sold you your existing policy to give you information about it. Hear both sides before you decide. That way you can be sure you are making a decision that is in your best interest. We are required by law to notify your existing company that you may be replacing their policy. Applicant Signature Applicant Name (Please print.) Producer Signature Producer Name (Please print.) MICHELLE TWANO Attention Consumer: This notice is required by the Insurance Commissioner. Please read it carefully before signing. Date Date Annuities Contract Number Contract Number Contract Number Existing Insurer Existing Insurer Existing Insurer Order # CA 09/01/2014

16 SUITABILITY PROFILE Voya Insurance and Annuity Company, Des Moines, IA ReliaStar Life Insurance Company, Minneapolis, MN - (Voya Retirement Index Select only) ReliaStar Life Insurance Company of New York, Woodbury, NY Voya Retirement Insurance and Annuity Company, Windsor, CT (the Company ) Members of the Voya family of companies Fax: Mail: PO Box 1337, Des Moines, IA Customer Service: 909 Locust Street, Des Moines, IA Website: Voya.com Phone: The purpose of this profile is to help ensure that the product you are purchasing is appropriate based on your financial situation and longterm goals. Please complete this profile in its entirety and submit it with your application. OWNER/JOINT OWNER INFORMATION FINANCIAL STATUS 1. The first year surrender charge for the Voya annuity applied for is (not applicable for SPIA)... %. 2. The surrender charge time period for the Voya annuity applied for is (not applicable for SPIA)... years. 3. Do you anticipate any of the following changes during the surrender charge period (or the payout period for your immediate annuity) indicated for the Voya annuity? If you answer yes to any part of question 3, please explain. If possible estimate when you expect changes and the amount. a. Significant increase/decrease in living expenses (e.g. housing, medical care, assisted living costs)... c Yes c No If yes, please explain: b. Significant increase/decrease in income (e.g. retirement, lower pension amount, change in jobs)... c Yes c No If yes, please explain: c. Significant increase/decrease in liquid assets (e.g. children s education, real estate transactions)... c Yes c No If yes, please explain: d. Significant increase/decrease in net worth (e.g. bonuses/stock options, inheritance, settlements)... c Yes c No If yes, please explain: 4. Federal income tax bracket: c 0% c 10% c 15% c 25% c 28% c 33% c 35% c % 5. The PRIMARY financial objective or intended use for purchasing this product is: c Income now c Guarantees provided c Growth potential c Growth, followed by income c Tax-deferred growth c Pass on to beneficiaries c Other 6. How many years of investment/financial experience do you have? c None c Less than 1 year c 1-2 years c 3-5 years c 5+ years Fixed Annuities Owner s name 1 : Current age: Anticipated retirement age: SSN/TIN: Are you actively employed? c Yes c No c Retired Joint owner s name: Current age: Anticipated retirement age: SSN/TIN: How long have you known the Producer? c Less than 1 year c 1 to 3 years c 3+ years Are you actively employed? c Yes c No c Retired For Trust Owned contracts - complete the form based on the Trust information as compared to the Annuitant or Grantor of the Trust. Note: Any death benefit is payable upon the death of the annuitant for Non-Natural Owned Annuity Contracts. 7. For SPIA only, is the annuity being purchased to fund the premium payments of a new life insurance policy?... c Yes c No 1 For non-individually owned (including Trusts) contracts, see producer guide for instructions on completion of form. Page 1 of 4 - Incomplete without all pages. Order # /31/2016

17 FINANCIAL STATUS (continued) MONTHLY HOUSEHOLD 4 INCOME Salary/wages $ Social Security payments Pension/retirement Annuity payments 1 Interest/dividend income Other (e.g; Rental income, unemployment benefits, please explain) Total income: $ 0.00 MONTHLY HOUSEHOLD 4 EXPENSES Rent/mortgage payment $ Utilities/transportation/food Debt repayment Health care/health insurance premiums Taxes 2 Other (e.g; Dependent support, charitable donations, please explain) Total expenses: $ 0.00 Anticipated payments from this SPIA (for immediate annuities only)... $ Total income $ 0.00 Total expenses $ 0.00 = Disposable income $ 0.00 Instructions for Household 4Net Worth/Liquid Assets: List your financial holdings under Net Worth in the left hand column and then of those holdings list the $ amount that is liquid in the right hand column. For further instruction/examples on how to fill out this section, please refer to the producer guide. HOUSEHOLD 4 NET WORTH/LIQUID ASSETS - DO NOT INCLUDE: Primary residence, personal belongings/property (e.g; jewelry, furnishings, vehicles) Estimated premium of proposed annuity $ HOUSEHOLD 4 NET WORTH Annuities (excluding premium of proposed annuity) 3 $ CDs Checking/savings/money market Pension/401K Stocks/bonds/mutual funds (other securities) Other (e.g; Cash value of life insurance, real estate, please explain) HOUSEHOLD 4 LIQUID ASSETS Total: $ $ What is your general risk tolerance? (check one) c c c c c Conservative Moderately Conservative Moderate Moderately Aggressive Aggressive 9. What is the source of this annuity s premium? (check all that apply) c Life insurance c Certificates of deposit c Stocks/bonds/mutual funds c Reverse mortgage c Home equity loan c Savings/checking/money market c Death benefit proceeds from life insurance/annuity c Annuity c Employer Retirement Plan (401(k), 403(b), etc.) c Other 10. Do you now have or have you ever had a reverse mortgage?...c Yes c No 11. Have you replaced or exchanged another annuity/life insurance policy within the past 5 years?...c Yes c No 1 Do not include income currently earned on money that will be used to purchase this annuity. 2 Include property taxes, income, and FICA taxes (if you are self-employed). 3 Do not include the value of assets used to purchase this annuity. 4 Household means applicant and spouse/partner, if a member of the applicant s household. Page 2 of 4 - Incomplete without all pages. Order # /31/2016

18 FINANCIAL STATUS (continued) If the purchase of the Voya annuity is a replacement or exchange you must complete questions 11a through 11n. To expedite processing, please attach a Replacement Comparison or a copy of your most recent statement for each replaced life insurance policy or annuity contract. CONTRACT 1 CONTRACT 2 11a. Type of contract/policy being replaced... c Indexed Annuity c Fixed Annuity c Indexed Annuity c Fixed Annuity c Variable Annuity c Variable Annuity c Life Insurance c Life Insurance 11b. Is the contract/policy being replaced less than 5 years old?... c Yes c No c Yes c No 11c. If yes, was the contract/policy part of a prior replacement or exchange?... c Yes c No c Yes c No 11d. Is there a surrender charge?... c Yes c No c Yes c No 11e. What is the current accumulation value?... $ $ 11f. What is the current surrender value?... $ $ 11g. What is the total amount being transferred?... $ $ 11h. What is the current death benefit on the contract/policy being replaced?... 11i. What is the current living benefit amount on the contract/policy being replaced? (If not applicable, list $0. Include riders and living benefits.)... 11j. What is the current interest rate and/or cap rate on contract/policy being replaced?... 11k. What is the Minimum Guaranteed Interest Rate MGIR on the contract/policy being replaced?... $ $ % % $ $ % % 11l. How many years of surrender charges remain on the contract being replaced?... 11m. What are the administrative/expense fees on contract/policy?... $ $ 11n. Explain why the existing life insurance policy or annuity contract cannot meet your financial objectives. Contract 1 Contract 2 ACCESSING YOUR MONEY 12. How do you anticipate taking withdrawals from this annuity? (check all that apply) c Required minimum distribution (IRA only) c Systematic withdrawals c Annuitize c Partial withdrawals c Enhanced withdrawal benefit c Lump sum c Immediate income c None anticipated 13. When do you anticipate taking your first withdrawal from this annuity? (choose one) c Less than 1 year c Between 1 and 5 years c Between 6 and 9 years c 10 or more years c None anticipated 14. By checking the box below (for SPIA only) c I acknowledge that I will only have access to the regular income stream provided by the SPIA. RIGHT TO EXAMINE AND RETURN You may return the Contract by mailing or delivering it to Customer Service at the address shown above or to the producer through whom you purchased it within twenty days (or thirty days if this is a replacement contract as defined by applicable state regulation) after the date you receive it. If so returned, we will promptly pay you any portion of the Premium paid and not previously surrendered, as well as any Premium Tax, if applicable, as of the date the returned Contract is received by us. If you are unsure whether your Contract is a replacement contract, please contact Customer Service. Page 3 of 4 - Incomplete without all pages. Order # /31/2016

19 OWNER ACKNOWLEDGEMENT By signing below, I understand that, if applicable to the annuity I purchased, I may incur a charge by taking money out of the annuity. If I purchased a SPIA, I understand that I will only have access to the regular income stream provided by the SPIA. I acknowledge that I reviewed the product-specific disclosure (if applicable) with my Producer. I understand the costs and features of the annuity I am purchasing. To the best of my knowledge the information I provided is true and complete and no required fields have been left blank. I understand that I should consult my tax advisor regarding tax implications of the purchase of an annuity or the exchange of an existing Employer Retirement Plan, Annuity or Life insurance policy. Owner s signature: Joint owner s signature: PRODUCER ACKNOWLEDGEMENT By signing below, I acknowledge that I have completed the product specific training and that I believe the annuity for which the owner(s) is applying is suitable, based on the information provided. I have provided all known details at this time. I have verified the identity of the owner(s) and believe that the identity information provided to me is true and accurate. Must be completed: The basis for my recommendation for the proposed annuity is: (If additional space is needed, include additional page(s) or use the back of this form.) Date: Date: Producer s signature: Date: Producer number: Page 4 of 4 - Incomplete without all pages. Order # /31/2016

20 NOTICE OF INFORMATION PRACTICES Voya Insurance and Annuity Company, Des Moines, IA Voya Retirement Insurance and Annuity Company, Windsor, CT ReliaStar Life Insurance Company, Minneapolis, MN (the Company ) Members of the Voya TM family of companies Fax: Mail: PO Box 1337, Des Moines, IA Customer Service: 909 Locust Street, Des Moines, IA Website: Voya.com Phone: Annuities ACCESS TO INFORMATION You may request access to certain personal information we collect to provide you with insurance products and services. You must make your request in writing and send it to the address above. Your letter should include your full name, address, telephone number and policy/contract number, if we have issued a policy/contract. Upon your request, we will send copies of the personal information to you. If the personal information includes medical record information, we may provide the medical record information to you through a medical professional designated by you. We will also send you information related to disclosures of your personal information, if requested. We may charge you a reasonable fee to cover our copying costs. Please note, this section and the Correction section below apply to personal information we collect to provide you with coverage. They do not apply to personal information we collect in connection with, or in anticipation of, a claim or civil or criminal proceeding. CORRECTION OF INFORMATION If you believe personal information we have about you is incorrect, please write to us. Your letter should include your full name, address, telephone number and policy/contract number, if we have issued a policy/contract. Your letter should explain why you believe the personal information is inaccurate. If we agree with you, we will correct, amend or delete the personal information in dispute and notify you of the correction. If you request us to do so, we will also notify any person who may have received the incorrect personal information from us in the past two years. If we disagree with you, we will tell you that we are not going to make the correction, amendment or deletion and give you the reason(s) for our refusal. If you wish, you may submit a statement to us setting forth the personal information you believe is the correct, relevant or fair information and/or setting forth the reason(s) you disagree with our decision not to correct, amend or delete the personal information. We will file your statement with the disputed personal information. We will include your statement anytime we disclose the disputed personal information. If you request us to do so, we will also give the statement to any person to whom we have disclosed the disputed personal information in the past two years. Page 1 of 1 Order # /01/2014

21 INSTRUCTIONS FOR SUBMITTING SUPPORT DOCUMENTS ELECTRONICALLY WITH APPLICATION Voya Insurance and Annuity Company Voya Retirement Insurance and Annuity Company ReliaStar Life Insurance Company of New York, Woodbury, NY (the Company ) Members of the Voya family of companies Fax: Mail: PO Box 1337, Des Moines, IA Customer Service: 909 Locust Street, Des Moines, IA Website: Voya.com Phone: Need to attach supporting documents to your application (letter of instruction or wet signed transfer paperwork, etc)? Follow the steps below and you can still electronically submit. INSTRUCTIONS Use the Documents task on the Other Actions menu to view application documents and add supplemental documents to the order package. 1. On the navigation bar, click Other Actions and then click Documents. X Other Actions Menu > Documents 2. In Application Documents to the right of Application, click the View link to open the application in a separate browser tab. Page 1 of 2 - Incomplete without all pages. Order # /01/2016

22 INSTRUCTIONS (CONTINUED) 3. Under Add Supplemental Document, select a document type and then click Choose File to select and add another document to the order package. The additional file name displays next to Choose File. X Other Actions Menu > Documents: Upload Supplemental Document 4. Click Upload to upload and add the file to the Application Documents. The supplemental document appears in the Application Documents section. X Other Actions Menu > Documents: Additional Application Documents 5. Click the Remove link on the right of any supplemental document to remove it from the Application Documents package. 6. Click X on the upper right to close the dialog box. Page 2 of 2 - Incomplete without all pages. Order # /01/2016