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Agent Name (Last) (First) (MI) (Jr / Sr)

AGENT APPOINTMENT REQUEST

Date Of Birth SSN Gender: c Male c Female

Residence Address

City State ZIP

Business Address

City State ZIP

Business Phone Business Fax

Email address

4. CORPORATE APPOINTMENT

FINRA Registered Broker-Dealer Name Tax ID #

Business Address

City State ZIP

Business Phone Business Fax

Issued by Voya Retirement Insurance and Annuity Company Voya Insurance and Annuity CompanyReliaStar Life Insurance Company of New York Registered products distributed by Directed Services, LLC., member FINRAMembers of the Voya® family of companiesFax: 515-698-2010Mail: PO Box 9216, Des Moines, IA 50306-9216 Customer Service: 909 Locust Street, Des Moines, IA 50309-2899Website: Voya.com Phone: 800-369-5305 Email: VoyaDS@voya.com

Tax ID # G.A. Name

Broker-Dealer Name c FID (Financial Institution Division)

CRD Number NPN

1. TYPE OF REQUEST

c Individual Appointment Request (Complete sections 1, 2, 3, 5 & 6.)c Corporate Appointment Request (Complete sections 1, 2, 4, 5 & 6.)c Broker-Dealer Change (Complete sections 1, 3, 5 & 6.)

2. COMPANY APPOINTMENT REQUEST

Annuities

*PIBSBPRDSRV0029PIBS*

Voya Retirement Insurance and Annuity Company (individual registered annuity products marketed under Annuities.)

Voya Insurance and Annuity Company and/or ReliaStar Life Insurance Company of New York (individual registered annuity products sold through Annuities.)

Voya Insurance and Annuity Company (individual non-registered annuity products (Select Rate and Select Multi-Index) marketed under Annuities.)

3. INDIVIDUAL APPOINTMENT

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1. Have you ever been discharged or permitted to resign from your employment appointment because you were accused of fraud or wrongful taking of property, violating investment-related or insurance-related statutes, regulations, rules or industry standards of conduct, or violating company rules? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Yes c No

2. Within the past 10 years, have you ever initiated bankruptcy proceedings or declared bankruptcy? . . . . . . . . . . . . . . . . . . . .c Yes c No

3. Do you have any knowledge of an indebtedness to an insurance carrier or financial organization that involves yourself or an organization you have been associated with, or do you have any unsatisfied liens or judgments?. . . . . . . . . . . . . . . . . . . . . c Yes c No

4. Within the past 10 years, has any insurance carrier canceled your contract or appointment for any reason other than lack of production?. .c Yes c No

5. Within the past 10 years, have you ever had a complaint filed against you that resulted in a fine, penalty, censure, cease and desist order, consent order or disciplinary action? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .c Yes c No

6. With the exception of routine traffic violations, have you ever been convicted of or pled guilty or nolo contendere (no contest) in a court to a misdemeanor or felony? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Yes c No

7. Are you involved in any pending or current litigation, investigations, complaints, or E & O claims or has any E & O carrier denied, paid claims on, or canceled your coverage?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Yes c No

8. Have you ever been named as a defendant or codefendant in a lawsuit, or have you ever sued or been sued by an insurance company? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Yes c No

9. Has a bonding company ever denied, paid out on, or revoked a surety or fidelity bond for you, or is there any reason you cannot secure a bond? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .c Yes c No

10. Have you ever been found guilty or nolo contendere (no contest) of violating state insurance department, federal or state securities or investment related regulation or statute, or have you ever had your insurance license or securities registration suspended, revoked, investigated, audited or had a license denied? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Yes c No

5. BACKGROUND INFORMATION

6. AUTHORIZATION AND ACKNOWLEDGEMENTS

I hereby certify that my answers to the questions contained in this application are true and correct. I acknowledge that Voya Insurance and Annuity Company, ReliaStar Life Insurance Company of New York or Voya Retirement Insurance and Annuity Company (hereinafter called the “Company,” “we,” or “us,” as the case may be) have informed me of the Company's practices to conduct routine investigative reports on agents for licensing purposes, initial and renewal state appointments, and at any time the Company, at its discretion, deems it necessary to conduct background investigations. I expressly authorize the Company to conduct these investigations and authorize all persons and entities (including past and present employers) to provide the Company all requested information.

I also expressly authorize the Company, for the purpose of facilitating the licensing and appointment process, to share information gathered as a result of these investigations with my agency and/or broker-dealer (including any third parties authorized by my agency and/or broker-dealer). I release from liability all persons and entities which supply said information to the Company and agree to hold the Company harmless from any liability for conducting this investigation. I authorize the Company to use these investigative reports and to provide these reports and any other pertinent information to all Voya affiliate companies and to third parties where the third parties’ legal interests and/or obligations are involved.

I authorize the Company to share any financial, business, legal, tax or work performance history regarding me that it receives from third parties, from any Voya affliliate companies or which is generated by the Company or from the Voya affiliate companies’ data source that is not part of the investigative report, with all other Voya affiliate companies. I also authorize the Company to share my debt balance information with agents, agencies or other third parties that assume my debt balance responsibilities, as well as debt collection agencies and debt reporting agencies.

I hereby authorize any employer, insurance company, general or managing agent, educational institution, financial institution, consumer reporting agency, criminal justice agency, insurance department, or individual having any information relating to my activities to release such information to insurance companies indicated on reverse side, Customer Service 909 Locust Street, Des Moines, IA 50309-2899 or any consumer reporting agency acting on behalf of the indicated insurance companies on the reverse side. This information may include, but is not limited to employment and job performance history, academic records, credit records, disciplinary, arrest and conviction records, and personal history, including information as to character, general reputation and mode of living.

I certify that I have reviewed this application and I understand that if any information provided in this application is found to be incorrect or incomplete, it will be grounds for rejecting this application or for termination of my appointment, all in the sole discretion of the company.

(Please respond to all questions for you personally and any organization over which you have exercised control. If you answer “yes” to any questions, you must attach an explanation with all relevant information and supporting documents.)

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7. TAX RESIDENCY INFORMATION

Signature of Representative or Signature of Principal Officer for Broker-Dealer Corporate Appointment.

Date Signature

Under penalty of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number; and

2. I am not subject to backup withholding because (a) I am exempt from backup withholding or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends or (c) the IRS has notified me that I am no longer subject to backup withholding; and

3. I am a U.S. citizen or other U.S. person (including U.S. resident alien) (As defined in instructions for IRS form W-9).

• If you are subject to back-up withholding, you must strike through statement number 2.

If you are not a US citizen or other US person please check the box below to indicate your status as a Non-Resident Alien.

c Non-Resident Alien (must submit an original IRS form W-8BEN or other applicable form W-8)

As a Non-resident Alien, your taxable income is subject to 30% US federal tax withholding unless tax treaty provisions can be applied. If you are eligible to claim tax treaty benefits, your IRS form W-8 must include a US taxpayer identification number in Part I and all applicable fields in Part II must be completed. A US taxpayer identification number may be applied for by submitting a Form W-7 to the Internal Revenue Service (IRS). lRS forms W-8 and W-7 are available on their web site at www.irs.gov or by contacting them at 800-829-1040.

I also acknowledge by my signature below that I authorize the Company, now or in the future, to obtain a consumer and/or investigative consumer report on me, and that I have received from the Company all disclosures required by the Fair Credit Reporting Act.

I agree to read and abide by the Company’s Business Guidelines and other Company policies and procedures located at https://forprofessionals.voya.com or www.voyaprofessionals.com.

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 backup withholding.

Voya Financial, Inc. and each of its subsidiaries (the "Company") disclose to you that a consumer report is being obtained from

a consumer reporting agency for the purpose of evaluating you for employment1 as an independent contractor. It may be an

"investigative consumer report" that includes information as to your character, general reputation, personal characteristics

and mode of living.

I acknowledge that my signature on the agent appointment application serves as an acknowledgement that I have received this Disclosure in accordance with the requirements under the Fair Credit Reporting Act, as amended.

• I authorize the Company, now and at any time while I am appointed and contracted to represent the Company for the sale and solicitation of the Company's products, to obtain a consumer report and/or investigative consumer report on me.

• I authorize and request any consumer reporting agency to furnish any and all information in their possession regarding me in connection with employment1 as an independent contractor. I authorize that a photocopy of this disclosure be accepted with the same authority as the original;

• I have the right to make a written request within a reasonable period of time to receive the additional, detailed information about the nature and scope of this investigation;

• I authorize the Company to share this information with the appropriate people in the Company, including but not limited to identified persons and those involved in the licensing and contracting process; and

• I understand I am not to solicit business on behalf of any Company until all required licenses and appointments have been obtained and all required contracts have been executed.

• I have received “A Summary of Your Rights Under the Fair Credit Reporting Act.”

California, Minnesota and Oklahoma Applicants Only. Please check here to have a copy of your consumer report sent directly to you by the appropriate credit repository.

If you have checked this box to receive a copy of your credit report, you must return this form with your agent contracting paperwork and provide your name and social security number below.

1Producers and agents are independent contractors, not employees. “Employment” is used in a non legal sense and includes qualification for certain programs available to independent contractors. Nothing in this form shall be construed to create an employer/employee relationship.

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PRODSRVCS_FCRA_Fair Credit Reporting Act

Social Security Number Name

FAIR CREDIT REPORTING ACT DISCLOSURE

*PIBSBPRDSRV0001PIBS*

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A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the fi les of consumer reporting agencies. There

are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check

writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including

information about additional rights, go to www.consumerfi nance.gov/learnmore or write to: Consumer Financial Protection Bureau, 1700 G

Street N.W., Washington, DC 20552.

• You must be told if information in your fi le has been used against you. Anyone who uses a credit report or another type of consumer report to deny

your application for credit, insurance, or employment — or to take another adverse action against you — must tell you, and must give you the name,

address, and phone number of the agency that provided the information.

• You have the right to know what is in your fi le. You may request and obtain all the information about you in the fi les of a consumer reporting

agency (your “fi le disclosure”). You will be required to provide proper identifi cation, which may include your Social Security Number. In many cases, the

disclosure will be free. You are entitled to a free fi le disclosure if:

• a person has taken adverse action against you because of information in your credit report;

• you are the victim of identify theft and place a fraud alert in your fi le;

• your fi le contains inaccurate information as a result of fraud;

• you are on public assistance;

• you are unemployed but expect to apply for employment within 60 days.

In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide

specialty consumer reporting agencies. See www.consumerfi nance.gov/learnmore for additional information.

• You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit

bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property

loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.

• You have the right to dispute incomplete or inaccurate information. If you identify information in your fi le that is incomplete or inaccurate, and

report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See www.consumerfi nance.gov/learnmore for

an explanation of dispute procedures.

• Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifi able information. Inaccurate, incomplete or unverifi able

information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has

verifi ed as accurate.

• Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative

information that is more than seven years old, or bankruptcies that are more than 10 years old.

• Access to your fi le is limited. A consumer reporting agency may provide information about you only to people with a valid need -- usually to consider

an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifi es those with a valid need for access.

• You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your

employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry.

For more information, go to www.consumerfi nance.gov/learnmore.

• You may limit “prescreened” off ers of credit and insurance you get based on information in your credit report. Unsolicited “prescreened”

off ers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these

off ers are based on. You may opt-out with the nationwide credit bureaus at 1-888-567-8688.

• You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information

to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.

• Identity theft victims and active duty military personnel have additional rights. For more information, visit www.consumerfi nance.gov/learnmore.

Para información en español, visite www.consumerfi nance.gov/learnmore o escribe a la Consumer Financial Protection Bureau,

1700 G Street N.W., Washington, DC 20552.

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States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. For more information about your federal rights, contact:

The consumer may also contact Voya’s background screening vendor. The consumer must provide proper identifi cation in order to inspect their fi le and the vendor will provide the consumer with trained personnel and explanation of any codes to help understand those fi les. The vendor's contact information is:

General Information Services PO Box 353, Chapin, SC 29036 Phone: 866-265-4917; Fax: 866-265-4921 Website: www.geninfo.com

TYPE OF BUSINESS CONTACT

1.a. Banks, savings associations, and credit unions with total assets of over $10 billion and their affi liates.

b. Such affi liates that are not banks, savings associations, or credit unions also should list, in addition to the Bureau:

a. Bureau of Consumer Financial Protection1700 G Street NW, Washington, DC 20552

b. Federal Trade Commission: Consumer Response Center – FCRAWashington, DC 20580(877) 382-4357

2. To the extent not included in item 1 above:a. National banks, federal savings associations, and federal branches and

federal agencies of foreign banks

b. State member banks, branches and agencies of foreign banks (other than federal branches, federal agencies, and insured state branches of foreign banks), commercial lending companies owned or controlled by foreign banks, and organizations operating under section 25 or 25A of the Federal Reserve Act

c. Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations

d. Federal Credit Unions

a. Offi ce of the Comptroller of the CurrencyCustomer Assistance Group1301 McKinney Street, Suite 3450, Houston, TX 77010-9050

b. Federal Reserve Consumer Help CenterPO Box 1200, Minneapolis, MN 55480

c. FDIC Consumer Response Center1100 Walnut Street, Box #11, Kansas City, MO 64106

d. National Credit Union AdministrationOffi ce of Consumer Protection (OCP)Division of Consumer Compliance and Outreach (DCCO)1775 Duke Street, Alexandria, VA 22314

3. Air carriers Asst. General Counsel for Aviation Enforcement & ProceedingsDepartment of Transportation400 Seventh Street SW, Washington, DC 20590

4. Creditors Subject to Surface Transportation Board Offi ce of Proceedings, Surface Transportation BoardDepartment of Transportation1925 K Street NW, Washington, DC 20423

5. Creditors Subject to Packers and Stockyards Act Nearest Packers and Stockyards Administration area supervisor

6. Small Business Investment Companies Associate Deputy Administrator for Capital AccessUnited States Small Business Administration406 Third Street, SW, 8th Floor, Washington, DC 20416

7. Brokers and Dealers Securities and Exchange Commission100 F St NE, Washington, DC 20549

8. Federal Land Banks, Federal Land Bank Associations, Federal Intermediate Credit Banks, and Production Credit Associations

Farm Credit Administration1501 Farm Credit Drive, McLean, VA 22102 5090

9. Retailers, Finance Companies, and All Other Creditors Not Listed Above FTC Regional Offi ce for region in which the creditor operates or Federal Trade Commission: Consumer Response Center – FCRAWashington, DC 20580(877) 382-4357

Additional Information about the Fair Credit Reporting ActThe Summary of Your Rights provided above does not refl ect certain amendments contained in the Consumer Reporting Employment Clarifi cation Act of 1998. The following additional information may be important for you:• Records of convictions of crimes can be reported regardless of when they occurred.• If you apply for a job that is covered by the Department of Transportation’s authority to establish qualifi cations and the maximum hours for that job

and you apply by mail, telephone, computer, or other similar means, your consent to a consumer report may validly be obtained orally, in writing, or electronically. If an adverse action is taken against you because of a consumer report for which you gave your consent over the telephone, computer, or similar means, you may be informed of the adverse action and the name, address and phone number of the consumer reporting agency, orally, in writing, or electronically.