Amendment to Original Application

Use this form if the insured person needs to switch his/her status to "non-tobacco user" for the purpose of premium rates. Not available on all plans.

Form for Association Group Term Life and Individual YRT Form Number

Amendment to Original Application for policies issued by ReliaStar Life Insurance Company

117064 (rev 9/01/14)

Amendment to Original Application for policies issued by ReliaStar Life Insurance Company of New York

117064 (rev 9/01/14)

Voya™ Employee Benefits insurance products and services in the U.S. are provided by ReliaStar Life Insurance Company (Minneapolis, MN) and ReliaStar Life Insurance Company of New York (Woodbury, NY). Within the State of New York, only ReliaStar Life Insurance Company of New York is admitted, and its products issued. Both are members of the Voya™ family of companies. Product availability and specific provisions may vary by state. Each insurer is solely responsible for the financial obligations under the policies or contracts it issues.