POLICY CHANGE REQUEST - GLPAgent

Order #119275 09/01/2014TM: CARTRNSSRAR eliaStar Life Insurance CompanyA member of the VoyaTM family of companies PO Box 5050, Minot, ND 58702-5050 Phone: 877-884-5050 TRANSMITTAL \ POLICY CHANGE REQUESTCity State ZIPC ontract Holder Name _____ Mailing Address _____Agent Name _____ Agent Name _____Contract Number _____SSN/TIN _____Phone_____Agent Number Agent Number Split % or $Split % or $PAYMENT CHANGE1 (Salary Reduction Agreement or Amendment to Employment Contract required.) Contract Type: c 403(b) c Roth 403(b) c 457 c Other _____PAYMENT SCHEDULE (If additional space is needed, use "Special Instructions" below.) CHANGE Employee/Employer Payment From $ _____ to _____ _____ _____Change Employee/Employer Payment From $ _____ to _____ _____ _____# PAYMENTSPAYDAY EFFECTIVEBILLING MODE: c 10 c 12 c 24 c 26 c Other: _____ OLD ANNUAL PREMIUM NEW ANNUAL PREMIUM NET CHANGE $ _____ $ _____ $ _____c Increase Payment c Restart c Decrease Payment c DiscontinueSPECIAL INSTRUCTIONS SIGNATURE FOR HOME OFFICE USE ONLY Profile Employer Number Date Last SAT SAT Amount Number of Pays Amount Received Agent S

Order #119275 09/01/2014 TM: CARTRNSSRA ReliaStar Life Insurance Company A member of the VoyaTM family of companies PO Box 5050, Minot, ND 58702-5050 Phone: 877-884-5050

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