Statement of Intent

(Life Insurance)

If group life insurance was assigned under a prior group policy, then in order to continue the assignment under the new Group Policy the insured person and the owner must complete and sign a Statement of Intent form.

The completed form must be sent to the insurer for approval, along with copies of all enrollment forms, beneficiary designations and the prior absolute assignment.

Form Name Form Number

Statement of Intent form for group life policies issued by ReliaStar Life Insurance Company

114963 (24661h) (rev 9/01/14)

Statement of Intent form for group life policies issued by ReliaStar Life Insurance Company of New York

116013 (46559d) (rev 9/01/14)

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