variable agent change request · variable agent of record change life reliastar life insurance...

Page 1 of 1 Order #142121 01/31/2020 PRODSRVCS_LIFEIND_LIFE_AGENTCHG NOTE: This document reflects the Company’s current standard practice and may be changed at any time without notice at Company’s sole discretion. The purpose of this signed authorization is to replace any existing registered representative that services the policy/contract with the new registered representative named below. This document supersedes any previous requests. The effective date of the change will be upon processing by the home office. POLICY INFORMATION VARIABLE AGENT OF RECORD CHANGE Life ReliaStar Life Insurance Company, Minneapolis, MN ReliaStar Life Insurance Company of New York, Woodbury, NY Security Life of Denver Insurance Company, Denver, CO Members of the Voya® family of companies 2000 21st Ave NW PO Box 5075 Minot, ND 58702-5075 Phone: 877-882-5050; Fax: 515-698-3844; Email: [email protected] *PIBSBPRDSRV0143PIBS* Date Registered Principal of Broker-Dealer/Firm Signature Date Client / Policy Owner Signature Accepting Broker-Dealer/Firm Name Additional Registered Representative Name Agent Number Additional Registered Representative Name Agent Number Client / Policy Owner Name Select the one of the following requests: Request from current broker-dealer/firm and new registered representative Required Signatures: Current broker-dealer/firm and client signature Request from new broker-dealer/firm and same registered representative Required Signatures: New broker-dealer/firm and client signature Request from new broker-dealer/firm and new registered representative Required Signatures: New broker-dealer/firm and client signature I authorize Voya Companies to disclose to my new registered representative/broker-dealer/firm information related to my policy or policies. VARIABLE LIFE POLICY AGENT OF RECORD CHANGE REQUEST AND REQUIREMENTS CLIENT AUTHORIZATION AND ACKNOWLEDGMENT BROKER-DEALER/FIRM AUTHORIZATION AND ACKNOWLEDGEMENT ADDITIONAL REGISTERED REPRESENTATIVE Only one registered representative is allowed to be listed as primary registered representative. Additional registered representatives will only be noted for phone support. Policy Number(s) (Required) Agent Number (Required) New Agent Email 1 (Required) New Agent Name (As it appears on insurance license) 1 An Agent email address is required for communications regarding the status of this request. Address (Required for MD residents) City State ZIP Address City State ZIP New Agent Address (Required for policies where the policy owner is located in MD) Policy Owner Name

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Page 1: Variable Agent Change Request · VARIABLE AGENT OF RECORD CHANGE Life ReliaStar Life Insurance Company, Minneapolis, MN ReliaStar Life Insurance Company of New York, Woodbury, NY

Page 1 of 1 Order #142121 01/31/2020 PRODSRVCS_LIFEIND_LIFE_AGENTCHG

NOTE: This document reflects the Company’s current standard practice and may be changed at any time without notice at Company’s sole discretion. The purpose of this signed authorization is to replace any existing registered representative that services the policy/contract with the new registered representative named below. This document supersedes any previous requests. The effective date of the change will be upon processing by the home office.

POLICY INFORMATION

VARIABLE AGENT OF RECORD CHANGE

Life

ReliaStar Life Insurance Company, Minneapolis, MNReliaStar Life Insurance Company of New York, Woodbury, NYSecurity Life of Denver Insurance Company, Denver, COMembers of the Voya® family of companies2000 21st Ave NWPO Box 5075Minot, ND 58702-5075Phone: 877-882-5050; Fax: 515-698-3844; Email: [email protected]

*PIBSBPRDSRV0143PIBS*

Date Registered Principal of Broker-Dealer/Firm Signature

Date Client / Policy Owner Signature

Accepting Broker-Dealer/Firm Name

Additional Registered Representative Name Agent Number

Client / Policy Owner Name

Select the one of the following requests: Request from current broker-dealer/firm and new registered representative

Required Signatures: Current broker-dealer/firm and client signature

Request from new broker-dealer/firm and same registered representativeRequired Signatures: New broker-dealer/firm and client signature

Request from new broker-dealer/firm and new registered representativeRequired Signatures: New broker-dealer/firm and client signature

I authorize Voya Companies to disclose to my new registered representative/broker-dealer/firm information related to my policy or policies.

VARIABLE LIFE POLICY AGENT OF RECORD CHANGE REQUEST AND REQUIREMENTS

CLIENT AUTHORIZATION AND ACKNOWLEDGMENT

BROKER-DEALER/FIRM AUTHORIZATION AND ACKNOWLEDGEMENT

ADDITIONAL REGISTERED REPRESENTATIVE

Only one registered representative is allowed to be listed as primary registered representative. Additional registered representatives will only be noted for phone support.

Policy Number(s) (Required)

Agent Number (Required) New Agent Email 1 (Required)

New Agent Name (As it appears on insurance license)

1 An Agent email address is required for communications regarding the status of this request.

Address (Required for MD residents) City State ZIP

Address City State ZIP

New Agent Address (Required for policies where the policy owner is located in MD)

Policy Owner Name

Voya - American Brokerage · Insurance Company or ReliaStar Life Insurance Company of New York (hereinafter called the “Company”) have informed me of the Company’s practices

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