Voya Claimant Statement – Fill Out and Use This PDF

CLAIMANT STATEMENT INSTRUCTIONS

HOW TO CONTACT US

•Customer Service: 800-369-5303. When prompted, confirm you are a beneficiary and enter the five-digit claim code (located on the enclosed letter). Press # to reach a claims specialist.

Hours: Monday–Friday, 8:30 a.m. to 6:00 p.m. Eastern Time.

•Please label all correspondence: Attn: Claims Department

GENERAL INFORMATION

If the decedent was a resident of any of the following states and date of death was prior to January 1, 2013, please follow the corresponding link provided to obtain an additional form that must be completed and submitted with this paperwork.

Contract information cannot be released until we have received a death certificate and IRS Form W-9 completed on behalf of the beneficiary. These documents can be faxed or mailed.

Claim information may only be released to the beneficiary or an authorized representative of the beneficiary.

Contract tax status and plan date can affect available options, as well as deadlines for filing a claim. See the enclosed letter for the applicable tax status and plan date.

If tax consequences are associated with the distribution, we will report this to the Internal Revenue Service and you will be provided with the appropriate tax form after the close of the calendar year. (Please note that tax consequences will be the responsibility of the named beneficiary and not the payee, if different.) Tax rules vary according to qualified or nonqualified contract status. Contact your independent tax advisor to learn which tax code section applies.

After a claim is processed, we will mail the claim proceeds. Please allow 7-10 business days for receipt.

Once you make an election of a settlement option, it cannot be changed and is irrevocable. If you wish to disclaim claim proceeds, beneficiaries must complete a separate form that may be requested through Customer Service. Please consult with your independent investment and tax advisors. There may be tax consequences with regard to claiming or disclaiming claim proceeds.

DOCUMENTS REQUIRED FOR PROCESSING A CLAIM

1) Death Certificate: Please send an original, certified death certificate. The death certificate must indicate the cause of death. When a person dies outside of the United States, please send a U.S. Consular's Report instead of a foreign death certificate.

2)Claimant Statement: See instructions on the next page. Send an original, signed copy to the mailing address above.

3)If the beneficiary is a:

MINOR

•Submit court paperwork showing appointment of the minor’s guardian or conservator, as required by each individual state’s regulations.

TRUST

•Submit a Certificate of Trust form.

ESTATE

•Submit letters of testamentary or a small estate affidavit. If the estate is not being probated and you are submitting a small estate affidavit, it must name the specific contract and the entity to pay. Note: A Last Will and Testament will not be accepted as proof of authority of executorship.

ORGANIZATION

•Submit a corporate resolution or meeting minutes that name authorized individuals and includes their signatures. This documentation must be on the organization's letterhead.

•Submit proof of nonprofit tax status if applicable.

INSTRUCTIONS FOR SECTION A: DECEDENT INFORMATION

Please complete this section in its entirety.

INSTRUCTIONS FOR SECTION B: BENEFICIARY INFORMATION

Please complete this section in its entirety unless otherwise indicated.

If you are one of the following beneficiary types, please follow the instructions specific to your type.

MINOR

Settlement Option Availability: All except Election of Continuance by Surviving Spouse.

Beneficiary Name: The minor’s full name.

SSN/ITIN: The minor’s SSN/ITIN, not the guardian’s.

TRUST

Settlement Option Availability: All except Election of Continuance by Surviving Spouse.

The trust must remain open the entire length of time that the Life Expectancy Deferral or 5-Year Deferral remains active. Beneficiary Name: The trust name. For example, “The John Doe Trust dated mm/dd/yyyy.”

Country of Citizenship: Trust situs (City and State).

Relationship to Decedent: “Trust”

Executor/Trust Name: The trustee's name and title. For example, "Name, Trustee."

TIN: The tax identification number (TIN) originally filed for the trust.

ESTATE

Settlement Option Availability: 5-Year Deferral and Lump Sum Payment only.

Note: If the claim proceeds are covered by a small estate affidavit, follow the directions for the beneficiary type named in the small estate affidavit, rather than these directions.

The estate must remain open the entire length of time that the 5-Year Deferral remains active. Beneficiary Name: The name of the estate. For example, “The Estate of John Doe.”

Country of Citizenship: Estate situs (City and State).

Relationship to Decedent: “Estate”

Executor/Trust Name: The executor's name and title. For example, "Name, Executor."

TIN: The estate identification number (EIN), not the executor's or decedent’s SSN.

CUSTODIAN (Financial Institution)

Settlement Option Availability: Election of Continuance by Surviving Spouse and Lump Sum Payment only.

Beneficiary Name: The custodian name. For example, “Custodian name, FBO (for the benefit of) Jane Doe.”

Country of Citizenship: Country of incorporation for the custodian.

Relationship to Decedent: “Custodian”

Executor/Trust Name: The authorized signer for the organization, with a title. For example, "Name, Title."

TIN: The custodian’s TIN, not the SSN for the beneficiary of the custodial account.

ORGANIZATION

Settlement Option Availability: 5-Year Deferral and Lump Sum Payment only.

Beneficiary Name: The name of the organization.

Country of Citizenship: Country where the organization was incorporated, organized, or formed.

Relationship to Decedent: “N/A”

Executor/Trustee Name: The authorized signer for the organization, with a title. For example, "Name, Title."

TIN: The TIN for the organization.

INSTRUCTIONS FOR SECTION C: SETTLEMENT OPTIONS

The following is an explanation of the settlement options. You may select only one. Once you make an election, it cannot be changed. Restricted beneficiary status can be designated by the contract owner and limits payout options for his or her beneficiary(s). If the enclosed letter indicates that this contract has a restricted beneficiary, please mail or fax a death certificate and an IRS Form W-9 completed by the beneficiary. After receiving these documents, we will be able to release information regarding this restriction to the beneficiary.

1.) ELECTION OF CONTINUANCE BY SURVIVING SPOUSE

This option is available only to a surviving spouse who is the sole beneficiary. This option may also be elected for custodial beneficiaries if the surviving spouse is the sole beneficiary of the custodial account.

By electing this option, the beneficiary chooses to become the owner and/or annuitant (same as the decedent). All provisions of the original contract and applicable riders apply, including the Surrender Charge Schedule.

If when the owner dies this contract is a 403(b)/TSA account, then as such the spouse cannot elect this option. However, the spouse may roll over claim proceeds to any qualified plan but must do so within 60 days from the date of distribution. To continue this contract as an IRA, the spouse must do two things:

1.Select the Election of Continuance by Surviving Spouse option on the Claimant Statement. There may be tax consequences associated with a rollover; please consult with an independent tax advisor. We will report to the IRS and provide the spouse with the appropriate tax form after the close of the calendar year. As a result of the rollover, we will also provide the spouse with an IRA endorsement to replace the 403(b) endorsement issued with the original contract.

2.Select the option in Section C to convert the contract to an IRA.

Note: You must check the box to continue previously elected payments. If this contract is on a systematic payment schedule, you must check one of the two options to either continue or stop the systematic payments.

If the original contract was the Voya Lifetime Income product, there are restrictions to spousal continuation of the Minimum Guaranteed Withdrawal Benefit (MGWB) rider under this contract, as follows:

For contracts with the Single Life MGWB rider in the Deferral Phase at time of death: The continuing spouse must be at least 50 years old in order to continue the MGWB rider. The continuing spouse becomes the annuitant and sole owner. The rider continues in the Deferral Phase and the Income Withdrawal Percentage (IWP) will be based on the age of the continuing spouse as of the date of death of the deceased spouse.

For contracts with the Single Life MGWB rider in the Income Phase at time of death: The MGWB rider can be continued only if the continuing spouse had been the annuitant prior to the date of death. If the continuing spouse had not been the annuitant prior to the date of death, the MGWB rider terminates. If the MGWB rider is in Automatic Periodic Benefit (APB) status and the annuitant dies, the contract and this rider terminate and will have no further value.

For contracts with the Joint Life MGWB rider: Upon the death of the owner (single ownership), or upon the first death of two joint owners (joint ownership), the surviving spouse may elect to continue the MGWB rider, provided that the surviving spouse is an active spouse and becomes the annuitant and sole owner.

You must elect to continue the MGWB rider by choosing this option in section C. If you do not make an election, the rider will terminate and have no further value.

2.) LIFE EXPECTANCY DEFERRAL OPTION (NON-ANNUITIZATION)

This option is NOT available if the beneficiary is an estate, custodian or organization.

By electing this option, the beneficiary will receive payments based on his or her life expectancy. Payments must be taken at least annually until the account assets are exhausted. Please select a payment frequency and start date on the Claimant Statement. Once your claim election is processed, the proceeds will earn a fixed rate of interest during the duration of the deferral period. The current deferral rate is listed on the cover letter of your claim paperwork but may change without notice. The deferral rate is guaranteed never to be below 0.1%.

If paperwork is received within the calendar year of the contract owner/annuitant's date of death, payments will not begin before January of the following calendar year. If paperwork is received in the calendar year following the contract owner/annuitant's date of death, payments will begin once completed paperwork has been received.

If the original contract was the Voya Lifetime Income product and paperwork is received within the calendar year of the contract owner/annuitant's date of death, payments will begin January of the following calendar year, unless a later date is specified. If paperwork is received in the calendar year following the contract owner/annuitant's date of death, payments will begin on the date you specify after completed paperwork has been received. Payments cannot begin later than the election deadline.

If the original contract was the Voya Journey product: Upon election of the LED option during the initial term (currently 7 years), the contract will continue to be invested in the same manner as prior to the death of the owner until the end of the initial term. Upon election of this option after the initial term, interest will follow the then current death benefit process. Contract values must be distributed over the life expectancy of the beneficiary with payments beginning within one year of the deceased owner's death.

If you are interested in electing this option, please call Customer Service at 800-369-5303 for assistance in determining whether there are any remaining years in the initial term, and to receive any other information regarding the original contract's investment selections that you may need to make your decision.

Exercise certain contract owner rights: You may name or change beneficiaries, but you cannot add additional premiums to the contract.

ELECTION DEADLINE (YOU MUST RECEIVE YOUR FIRST PAYMENT):

Tax Qualified: December 31 of the year following the owner’s date of death.

Tax Nonqualified: First anniversary of the owner’s date of death.

INSTRUCTIONS FOR SECTION C: SETTLEMENT OPTIONS (CONTINUED)

3.) 5-YEAR DEFERRAL OPTION

This option is NOT available if the beneficiary is a custodian.

If the beneficiary is an estate, the estate must remain open for the five-year period to elect this option.

By electing this option, the beneficiary is delaying receipt of the claim proceeds until the end of the deferral period. By electing

this option, you will be entitled to limited rights of ownership of the original contract. For example, you may name or change beneficiaries, but you cannot add additional premiums to the contract. Systematic withdrawals are not available with this option. You may withdraw from the contract without surrender charges until the proceeds and interest are exhausted. Withdrawals may be arranged by contacting the Company and will require processing time. Once your claim election is processed, the proceeds will earn a fixed rate of interest during the duration of the deferral period. The current deferral rate is listed on the cover letter of your claim paperwork but may change without notice. The deferral rate is guaranteed never to be below 0.1%. You will receive statements, if applicable. To receive payments before the end of the deferral period, the beneficiary must submit a request in writing that includes the contract number and tax withholding instructions. Claim proceeds will be paid upon request. A Financial Services (RFS) form must be submitted for a withdrawal of proceeds.

Exercise certain contract owner rights: You may name or change beneficiaries, but you cannot add additional premiums to the contract.

ELECTION DEADLINE (DEFERRAL PERIOD ENDS):

Tax Qualified: December 31 of the fifth year following the owner’s date of death.

Tax Nonqualified: Fifth anniversary of the owner’s date of death.

4.) INCOME PLAN SELECTION (ANNUITIZATION OPTION)

This option is NOT available if the beneficiary is an estate, custodian or organization.

By electing this option, the beneficiary is annuitizing the claim proceeds to provide a stream of guaranteed payments for the frequency and time period indicated on the Claimant Statement. Please select a payment frequency, start date and preferred income plan on the Claimant Statement. If the Joint Life Income plan is selected, complete the joint annuitant information as well. For more information on Income Plan options, or to obtain a quote, please contact Customer Service to speak to a claims specialist.

ELECTION DEADLINE (YOU MUST RECEIVE YOUR FIRST PAYMENT): Tax Qualified: December 31 of the year following the owner’s date of death. Tax Nonqualified: First anniversary of the owner’s date of death.

5.) LUMP SUM PAYMENT

By electing this option, the beneficiary will receive a lump sum payment for the full claim proceeds. The following options are available if electing this option.

If you are a spouse of the deceased contract owner you may elect one of the following options:

•Lump sum payment by check made payable the beneficiary.

•Spousal Transfer / Rollover. If the underlying contract is qualified, you may have the funds sent to another IRA or qualified account in your name on a tax free basis.

•Transfer. Funds are transferred directly within Voya* or to another financial institution into an IRA or qualified account in your name on a tax free basis. A Letter of Acceptance is required from the receiving financial institution. This election results in no federal tax reporting. Note: if you choose this option and do not submit a Letter of Acceptance, your request will be processed as a Rollover.

•Rollover. Funds are sent directly within Voya* or another financial institution into an IRA or qualified account in your name on a tax free basis. A Letter of Acceptance is not required from the receiving institution; however, this election is a federal tax reportable event. The receiving institution is required to tax report the incoming funds appropriately.

•Exchange. If the underlying contract is non-qualified, you may have the funds sent to another annuity contract within Voya* or another financial institution on a tax free basis via a 1035 Exchange. Completed 1035 paperwork with absolute assignment and Letter of Acceptance from the receiving institution is required. This election is a federal tax reportable event.

If you are NOT the spouse of the deceased contract owner you may elect one of the following options:

• Lump sum payment by check made payable the beneficiary.

ELECTION DEADLINE:

Tax Qualified: December 31 of the fifth year following the owner’s date of death.

Tax Nonqualified: Fifth anniversary of the owner’s date of death.

INSTRUCTIONS FOR SECTION C: SETTLEMENT OPTIONS (CONTINUED)

5.) LUMP SUM PAYMENT (CONTINUED)

•Transfer. If the underlying contract is qualified, you may have the funds transferred to an inherited IRA within Voya* or another financial institution on a tax free basis. A Letter of Acceptance is required from the receiving financial institution. This option results in no federal tax reporting.

•Exchange. If the underlying contract is non-qualified, you may have the funds exchanged to an inherited non-qualified annuity within Voya* or another financial institution on a tax free basis via a 1035 Exchange. Completed 1035 paperwork with absolute assignment and Letter of Acceptance from the receiving institution is required. This election is a federal tax reportable event.

ELECTION DEADLINE (MUST RECEIVE FIRST PAYMENT):

Tax Qualified: December 31 of the year following the owner’s date of death.

Tax Nonqualified: First anniversary of the owner’s date of death.

*For Transfers and Exchanges to a Voya product, the proceeds will not be distributed until the new account application is received. If you are purchasing a Voya product, please complete Section D.

6.) RESTRICTED BENEFICIARY

If you are a restricted beneficiary, your death benefit payout option was elected by the deceased contract owner. Please complete Section B with restricted beneficiary information requested. Once you have completed and returned a W-9 and death certificate, please call Customer Service for your death benefit restriction designation.

INSTRUCTIONS FOR SECTION D: ALTERNATE PAYEE/ALTERNATE ADDRESS INFORMATION

Complete this section only if you want your claim proceeds payable to another party and/or mailed to an alternate address.

Note: Tax consequences will be the responsibility of the named beneficiary, not the alternate payee. We will not make the check payable to a trustee, executor or an individual having power of attorney.

INSTRUCTIONS FOR SECTION E: NEW BENEFICIARY DESIGNATION

Not available for Trusts, Estates, or Organizations. Complete this section if you elected an option other than Lump Sum Payment. If you need space for additional beneficiaries, please attach a separate sheet signed and dated by the new contract owner. If no beneficiary is named, the beneficiary will default to your estate.

INSTRUCTIONS FOR SECTION F: PRODUCER DESIGNATION

This section applies to beneficiaries who have elected: Spousal Continuance, Life Expectancy Deferral, 5 Year Deferral and Income Plan (annuitization). If a selection is not made in this section, a producer will not be listed on the contract.

INSTRUCTIONS FOR SECTION G: 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.

Eligible rollover distribution—20% withholding: Distributions from your 403(b) or Governmental 457 that are eligible to be rolled over tax free to an IRA or another qualified plan are subject to a flat 20% federal withholding rate. The 20% withholding rate is required, and you cannot choose not to have income tax withheld from eligible rollover distributions. You may elect withholding in excess of the mandatory 20% rate.

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”. Note: Periodic payments made from qualified retirement plans that are not based on life expectancy and are expected to last less than 10 years remain rollover eligible and are subject to the mandatory 20% withholding described above.

INSTRUCTIONS FOR SECTIONS H AND I: IMPORTANT INFORMATION AND STATE REQUIRED NOTICES AND AUTHORIZATION AND SIGNATURES

Read the information in these sections.

MINOR: All acting guardians must sign documents in the "James Smith, Guardian" format. Please note that regardless of relationship to the minor, court-issued documents naming the signer as legal guardian are required in most states. The requirement for court- issued documents may depend on the amount of the claim proceeds.

TRUST: All acting trustees must sign documents in the “James Smith, Trustee” format.

ESTATE: All acting executors must sign documents in the “James Smith, Executor” format.

CUSTODIAN (Financial Institution): Only authorized individuals for the custodian may sign, based on the custodial agreement with us. Custodians must sign documents in the “James Smith, Title” format.

CUSTODIAN (Individual Beneficiary): Custodians named by the owner within the beneficiary designation and acting on behalf of the named beneficiary must sign documents in the “James Smith, Custodian for [beneficiary name]” format.

ORGANIZATION: All authorized signers must sign documents in the “James Smith, Title” format.

RESET FORM

CLAIMANT STATEMENT

Street Address (PO boxes are not permitted.)

If the beneficiary is a trust, estate or entity, complete the information below and provide additional required documentation as described in the instructions.

C.SETTLEMENT OPTIONS (Please select only one option.)

1. Election of Continuance by Surviving Spouse (Check all that apply. Designate new beneficiaries in Section E.)

I elect to continue the receipt of payments in the method previously elected under this contract.

I elect to stop the receipt of payments.

Voya Lifetime Income product only (You must select one option.):

1A.  I elect to continue the base contract.

1B.  I elect to continue the Minimum Guaranteed Withdrawal Benefit (MGWB) rider on the contract.

1C.  I elect to continue the MGWB rider with the optional Guaranteed Death Benefit (GDB) Base on the contract. (This option is available to you only if the GDB Base was elected at the time the original contract was issued.)

403(b) contracts only:

In order to continue this contract:

I elect to convert the contract to an IRA through a direct rollover1. I understand there may be tax consequences associated with a rollover and have consulted with an independent tax advisor.

1We will report the rollover to the IRS and provide you with the appropriate tax form after the close of the calendar year. As a result of the rollover, we will also provide you with an IRA endorsement to replace the 403(b) endorsement issued with the original contract.

C. SETTLEMENT OPTIONS (CONTINUED)

2. Life Expectancy Deferral Option (Non-Annuitization) (Designate new beneficiaries in Section E.)

•Please select payment frequency:  Monthly  Quarterly  Semi-Annually  Annually

Start Date (1-28)1

Once your claim election is processed, the proceeds will earn a fixed rate of interest during the duration of the deferral period. The current deferral rate is listed on the cover letter of your claim paperwork but may change without notice. The deferral rate is guaranteed never to be below 0.1%.

1See the Instructions area for specific details about payment start dates.

3. 5-Year Deferral Option (Designate new beneficiaries in Section E.)

•A Request for Financial Service (RFS) form must be submitted for a withdrawal of proceeds. Systematic withdrawals are not available with this option.

Once your claim election is processed, the proceeds will earn a fixed rate of interest during the duration of the deferral period. The current deferral rate is listed on the cover letter of your claim paperwork but may change without notice. The deferral rate is guaranteed never to be below 0.1%.

4. Income Plan Selection (Annuitization Option) (Designate new beneficiaries in Section E.)

•If Start Date and/or payment frequency is not chosen, the default start date will be current date and the default frequency will be monthly.

•Please select payment frequency:  Monthly  Quarterly  Semi-Annually  Annually

1We will pay equal periodic payments during the specified period. If the annuitant dies, any remaining payments will be paid to the beneficiary.

2The number of years available may be limited by governmental, tax and/or contractual regulations and provisions.

3We will pay equal payments during the lifetime of the annuitant. If the annuitant dies during the specified period, the balance of the specified period payments, if any, will be paid to the beneficiary.

5.Lump Sum Payment

If you are a spouse of the deceased contract owner you may elect one of the following options:

Lump Sum Payment by check made payable to the beneficiary. A check will be sent to the address indicated in Section B or, if completed, Section D of the Claimant Statement.

Note: Spousal Transfer / Rollover. If the underlying contract is qualified, you may have the funds sent to another IRA or qualified account in your name, on a tax free basis.

Transfer. Funds are transferred directly within Voya* or to another financial institution into an IRA or qualified account in your name on a tax free basis. A Letter of Acceptance is required from the receiving financial institution. This election results in no federal tax reporting. Note: if you choose this option and do not submit a Letter of Acceptance, your request will be processed as a Rollover.

Rollover. Funds are sent directly within Voya* or another financial institution into an IRA or qualified account in your name on a tax free basis. A Letter of Acceptance is not required from the receiving financial institution; however, this election is a federal tax reportable event. The receiving institution is required to tax report the incoming funds appropriately.

Exchange. If the underlying contract is non-qualified, you may have the funds sent to another annuity contract within Voya* or another financial institution on a tax free basis via a 1035 Exchange. Completed 1035 paperwork with absolute assignment and Letter of Acceptance from the receiving institution is required. This election is a federal tax reportable event.

C. SETTLEMENT OPTIONS (CONTINUED)

5.Lump Sum Payment (Continued)

If you are NOT the spouse of the deceased contract owner you may elect one of the following options:

Lump Sum Payment by check made payable to the beneficiary. A check will be sent to the address indicated in Section B or, if completed, Section D of the Claimant Statement.

Transfer. If the underlying contract is qualified, you may have the funds transferred to an inherited IRA within Voya* or another financial institution on a tax free basis. A Letter of Acceptance is required from the receiving financial institution. This election results in no federal tax reporting.

Exchange. If the underlying contract is non-qualified, you may have the funds exchanged to an inherited non-qualified annuity within Voya* or another financial institution on a tax free basis via a 1035 Exchange. Completed 1035 paperwork with absolute assignment and Letter of Acceptance from the receiving institution is required. This election is a federal tax reportable event.

*For 1035 Exchanges, Transfers or Rollovers to a Voya product, the lump sum distribution will not be processed until the new account application is received. By selecting this option, you hereby direct us to pend the processing of the distribution until the new account application is received.

6.  Restricted Beneficiary

By checking this box, you accept the claim proceeds as outlined for this contract.

D. ALTERNATE PAYEE/ALTERNATE ADDRESS INFORMATION (Complete if you would like payments sent to a different individual or entity or if you would like payments sent to an address other than the address listed in Section B.)

Note: Tax consequences will be the responsibility of the named beneficiary, not the alternate payee.

We will not make the check payable to a trustee, executor or an individual having power of attorney.

Payee Name

Address

E.NEW BENEFICIARY DESIGNATION (Not available for Trusts, Estates, or Organizations.)

Additional beneficiaries should be listed on a separate piece of paper that is signed and dated by the new contract owner.

F.PRODUCER DESIGNATION (If a selection is not made below, a producer will not be listed on the contract.)

c I would like to maintain the current producer on the contract.

c I would like to name a new producer on the contract. (If selected, please complete information below.)

c I give the Company permission to discuss the details of my request with the new producer named on the contract. Producer Name

Address

Please verify that there is a selling agreement in place between your newly appointed financial advisor’s Broker-Dealer and the Company. If a selling agreement has not been approved, the processing of this request may be delayed. If your account is registered under a Broker-Dealer custodial account, we suggest you submit a change of ownership form if the new custodian will be changed as a result of this request.

G. TAX WITHHOLDING ELECTION

FEDERAL WITHHOLDING INSTRUCTIONS:

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. If no election is made, the default rate will be applied.

side 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

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.

H. IMPORTANT INFORMATION AND STATE REQUIRED NOTICES

To help the government fight the funding for terrorism and money laundering activities, federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means to 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.

Below are notices that apply only in certain states. Please read the following carefully to see if any apply in your state.

Alaska, Alabama, Arkansas, Delaware, Idaho, Indiana, Louisiana, Maine, Minnesota, Ohio, Oklahoma, Rhode Island, Tennessee, Texas, Washington, West Virginia: Any person who, knowingly with intent to defraud any insurance company or other person files a 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 may subject such person to criminal and civil penalties, and denial of insurance benefits.

Arizona: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

California: For your protection, California law requires the following to appear on this form. Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

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 policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder 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 a 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.

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.