POLICY CHANGE REQUEST - GLPAgent

1 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 Signature _____Date _____ State Signed _____NON-BILLING MONTHS _____White: Voya Canary: Employer Pink: Agent Goldenrod: EmployeeTYPE OF CHANGE .

2 1 For contract holders with more than one contract, we will require the Contribution Allocation portion of the REQUEST for Salary Reduction Agreement and Contribution Allocation form to be completed and attached.