Voya Claimant Form Details

The Voya Claimant Statement Form is an important document for those who are seeking to file a disability claim with their insurance provider. This form can be used to provide key information about the individual's disability and how it is impacting their life. Filling out this form accurately and completely can help to ensure that the claimant's case is reviewed thoroughly and efficiently.

You could find it useful to understand the amount of time you'll need to fill out this voya claimant statement and how long this document is.

QuestionAnswer
Form NameVoya Claimant Statement
Form Length12 pages
Fillable?No
Fillable fields0
Avg. time to fill out3 min
Other namesvoya insurance claim form, voya proof of death claimant's statement, voya claim form, print voya claim forms

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CLAIMANT STATEMENT INSTRUCTIONS

Voya Insurance and Annuity Company, Des Moines, IA

 

Voya Retirement Insurance and Annuity Company, Windsor, CT

 

ReliaStar Life Insurance Company of New York, Woodbury, NY

 

Security Life of Denver Insurance Company, Denver, CO

 

Members of the Voya® family of companies

 

(the "Company")

 

Fax: 515-698-2001

 

Mail: PO Box 1337, Des Moines, IA 50305-1337

 

Customer Service: 699 Walnut Street STE. 1350, Des Moines, IA 50309-3942

Fixed Annuities

Website: Voya.com Phone: 800-369-5303

 

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.

• Indiana

https://forms.in.gov/Download.aspx?id=2699

• Ohio

http://www.tax.ohio.gov/portals/0/forms/estate/2012/ET_ET13_FI.pdf

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.

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Order #145146 06/01/2018

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.

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Order #145146 06/01/2018

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.

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Order #145146 06/01/2018

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.

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Order #145146 06/01/2018

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.

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Order #145146 06/01/2018

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.

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Order #145146 06/01/2018

CLAIMANT STATEMENT

Voya Insurance and Annuity Company, Des Moines, IA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Voya Retirement Insurance and Annuity Company

 

 

 

 

 

 

 

 

ReliaStar Life Insurance Company of New York, Woodbury, NY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Security Life of Denver Insurance Company, Denver, CO

 

 

 

 

 

 

 

 

Members of the Voya® family of companies

 

 

 

 

 

 

 

 

(the "Company")

 

 

 

 

 

 

 

 

 

 

 

 

 

Fax: 515-698-2001

 

 

 

 

 

 

 

 

 

 

 

 

 

Mail: PO Box 1337, Des Moines, IA 50305-1337

 

 

 

 

 

 

 

 

Customer Service: 699 Walnut Street STE. 1350, Des Moines, IA

50309-3942

 

 

 

Fixed Annuities

Website: Voya.com

Phone: 800-369-5303

 

 

 

 

 

 

 

 

A. DECEDENT INFORMATION

 

 

 

 

 

 

 

 

Decedent First Name

MI

Last Name

Contract #

 

 

 

 

SSN

 

 

 

 

 

 

Date of Death

 

B. BENEFICIARY INFORMATION

 

 

 

 

 

 

 

 

Beneficiary Name

 

 

 

 

 

 

 

 

 

 

Gender

Country of Citizenship

 

Relationship to Decedent

 

 

Street Address (PO boxes are not permitted.)

City

 

 

 

 

State

 

 

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address (If different than above.)

 

 

 

 

 

City

 

 

 

 

 

State

 

 

ZIP

 

If the beneficiary is

an individual, complete the information below. If the beneficiary is

also a

minor, provide proof of guardianship.

Date of Birth

 

 

 

SSN/ITIN

 

Phone

 

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

Executor/Trustee Name

 

TIN

Phone

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.

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Order #145146 06/01/2018

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

Start Date

 

 

 

 

 

 

 

 

 

 

 

Payments for1 5 years

10 years

15 years

20 years

Other2

 

 

Life income with payment for3

5 years

10 years

15 years

20 years Other2

Joint Life Income

 

 

 

 

 

 

 

 

 

 

Joint Life Name

 

 

 

 

Date of Birth

 

 

SSN

 

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.

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Order #145146 06/01/2018

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

City

 

State

 

ZIP

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

Name

Gender

Birth Date/Trust Date

SSN/TIN

%

 

 

 

 

Beneficiary Type:

Address

 

Phone

Relationship to Owner

Primary

Name

Gender

Birth Date/Trust Date

SSN/TIN

%

 

 

 

 

Beneficiary Type:

Address

 

Phone

Relationship to Owner

Primary

 

Contingent

 

 

 

 

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.)

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

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

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.

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Order #145146 06/01/2018

G. TAX WITHHOLDING ELECTION

FEDERAL WITHHOLDING INSTRUCTIONS:

I do not want to have federal income tax withheld from my distribution.

 

 

 

 

I would like to have the following federal income tax withheld from my distribution: $

 

or

%.

Marital Status: Single Married Married, but withhold at higher “Single” rate

 

 

 

 

Total number of Allowances:

 

 

 

 

 

 

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.

STATE WITHHOLDING INSTRUCTIONS:

 

My residence state for tax purposes is

(If your current physical and/or mailing address is out-

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 one is not specified, we will presume this income is not reportable to any U.S. state or territory.)

I do not want to have state income tax withheld from my distribution.

 

 

I would like to have the following state income tax withheld from my distribution: $

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.

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.

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Order #145146 06/01/2018

H. IMPORTANT INFORMATION AND STATE REQUIRED NOTICES (CONTINUED)

New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in NH Rev. Stat. Ann. §638.20.

New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information 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 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.

I. AUTHORIZATION AND SIGNATURES

I acknowledge that I have considered my election options carefully and I fully understand that my election is irrevocable and cannot be changed once it has been processed.

There may be tax consequences with regard to this request. Please consult with your independent investment and tax advisors for more details.

I hereby certify that I have read and understand the terms of this form and that the information provided on this form is true and complete to the best of my knowledge.

If electing Continuance by Surviving Spouse in Section C, then indicate below what type of advice you received in connection with the requested transaction.

(Select one.)

Producer/Agent Advised

Self Advised (Owner Driven)

Third Party/Other Advised

New York Residents: 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 shall also be subject to

a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

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.

3.I am a U.S. person.

NON-RESIDENT ALIEN STATUS

If you are a Non-Resident Alien, please check the box and provide your country of residence below.

Under penalties of perjury, I certify that I am a Non-Resident Alien and my country of residence is:

 

.

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.

Beneficiary Signature

 

Date

 

 

 

Beneficiary Title

 

 

 

If the beneficiary is a trust, partnership, or corporation, officer signature and title of the trustee, partner, corporate representative or authorized corporate representatives are required.

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Order #145146 06/01/2018

STATE INCOME TAX WITHHOLDING NOTIFICATION

NotificatioN

If you are a resident of arkansas, california, connecticut, Delaware, District of columbia, Georgia1, iowa, Kansas, Maine, Maryland1, Massachusetts, Michigan, Nebraska2, North carolina3, oklahoma, oregon, Vermont, or Virginia1, your state requires

state income tax withhoon the taxaof your distrifrom your Por

annuitystate income tax withhois in addition to the mandatory 20in some cases10federaincome tax withhoPnotewhen a state cost differs from federathe federacost wiused in determining taxa for state income tax withho

If you are a resident of california or oregon state income tax withhowi caunyou comthe state withhoequest indicating your e

If you are a resident of arkansas, North carolina or Vermont, state withhowiautomaticacawhen federa income tax withhoaIf you do not e“out” of 10federaincome tax withhoyou can stichoose to eout

of state withhoequesting withhoomandatory amounts requires their ension or ayments

• If you are a resident of iowa, Maine, Massachusetts, Nebraska2or oklahomastate income tax withhowiautomatica caas these states do not aan e“out” of state income tax withhowhen federaincome tax withho

a

If you are a resident of Delaware, Kansas or Maryland1 and are suto mandatory 20federaincome tax withho state income tax withhowi automaticacatate withhois not required when 10federaincome tax

withho

• If you are a resident of Virginia1 or Michiganstate income tax withhowi caautomatica

unless you meet

certain criteria and c an exem from withhoo c an exem or to request withho o mandatory

 

amountscomfor or for and return the aform to us withand to the

 

same designated equest

 

If you are a resident of the District of columbia4 and are receia totadistriof your account state income tax withhotate withho

If you are a resident of Georgia1 and are receistate income tax withhowiautomaticaca un

If you are a resident of connecticut and are receinonstate income tax withhowitaen at the highest marginarate unyou cexemfrom withhoor request additionawithhocom If you are receia totaof your account state income tax withhowitaen at the highest marginarate unyou request additionawithhocomou cannot cexemfrom withho

for a totaIf you are receia state income tax withhowitaen at the highest margina rate unyou commust returned to us withand to the same designated asyour

equest

1

2

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 #165566 12/10/2018

KEEP WITH CUSTOMER