Page 1 of 4 Order #155669 09/01/2014TM: TSANBFIXED/INDEX

The purpose of this profile is to help ensure that the annuity you are purchasing is appropriate based on your financial situation and long-term goals and that you understand certain features of the annuity. Please complete this profile in its entirety and submit it with your application.

A. Owner/jOint Owner infOrmAtiOn

Owner Name Are you actively employed? c Yes c No1 c Retired

B. finAnciAl OBjectives And cOnsiderAtiOns1. Why are you considering purchasing this annuity? (Check all that apply.) c Immediate Income c Income Features c Lifetime Income c Capital Preservation c Death Benefit c Tax Deferral c Minimum Guarantees c Pass Assets to Beneficiaries c Other

3. Which financial products do you own or have you previously owned? (Check all that apply.) c Variable Annuities c Fixed Annuities c Fixed Index Annuities c Stocks/Bonds/Mutual Funds c Certificate of Deposit (CD) c Life Insurance c None

4. Indicate the source(s) of funds to be used for the purchase of the annuity. (Check all that apply.) c Salary Deferral c Employer Retirement Plan (401(k), etc.) c Individual Variable Annuities c Individual Fixed Annuities c Individual Fixed Index Annuities c Stocks/Bonds/Mutual Funds c Certificate of Deposit (CD) c Savings/Checking/Money Market c Life Insurance c Other

1 If unemployed, please provide source of income

2. What is your risk tolerance? (Check one.) c Aggressive c Moderate c Conservative If aggressive, please explain how this fixed deferred annuity fits into your overall financial objectives:

5. a. Have you ever replaced or exchanged another annuity? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Yes c No b. If “Yes,” when was the most recent replacement or exchange? . . . . . . . . . . . . . . c 0-3 years c 4-5 years c More than 5 years c. If “Yes,” to B5a, has any source of funds for this annuity purchase been included in any of those exchanges? . . . . . . . . . . . c Yes c No

Joint Owner Name Are you actively employed? c Yes c No1 c Retired

6. If the source of funds is an annuity or life insurance policy:a. Please explain how this new annuity better meets your objectives.

Issue State SSN/TIN Current Age Anticipated Retirement Age

Issue State SSN/TIN Current Age Anticipated Retirement Age

If “Yes,” please explain.

If “Yes,” please explain.

c. Are there any changes in contract fees/provisions (i.e., surrender charges, surrender charge period, death benefit fees, rider/living benefit fees, mortality/expense fees, investment advisory fees, etc.)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Yes c No

b. Are there any losses or changes of any benefits (i.e., death benefits, living benefits, or other contractual benefits, etc.)? . . c Yes c No

If “Yes,” please explain.

d. Are there any changes or limitations on interest returns (i.e., market value adjustment, index caps/spreads/participation rates, potential loss of bonus, change of market risk, etc.)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Yes c No

ReliaStar Life Insurance Company, Minneapolis, MNA member of the VoyaTM family of companiesCustomer Service: PO Box 5050, Minot, ND 58702-5050

SUITABILITY PROFILE (DEFERRED ANNUITIES ONLY)Required form for: All IRA/NQ sales - all ages; 403(b)/457 sales if age 65 and over

Page 2 of 4 Order #155669 09/01/2014TM: TSANBFIXED/INDEX

d. finAnciAl infOrmAtiOn (Income/Expenses)

6. Is the annuity purchase payment more than four (4) times your annual income? . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Yes c No

1. Approximate current monthly household income $ /mo• Including,butnotlimitedtosalary,SocialSecuritypayments,pension/retirementbenefits,investmentandrentalincome• Donotincludeincomecurrentlyearnedonthemoneythatwillbeusedtopurchasethisannuity

5. a. The surrender period of the annuity applied for is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . years b. If a replacement, the remaining surrender period on the existing life insurance or annuity is . . . . . . . . . . . . . . . . . . . years c. Do you anticipate any significant increase in living expenses or decrease in your household’s monthly income during the surrender period? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Yes c No • Examplesofareductioninhouseholdincomemightberetirementoralowerpensionpayment

• Examplesofincreasesinlivingexpensesmightbehousing,medical,nursinghome,assistedliving,ortravelexpenses• Ifyouanswered“Yes”to5.c.,pleaseexplain.(If possible, approximate when you anticipate changes in income, living expenses, and the amount.)

2. Approximate current monthly household living expenses $ /mo• Including, but not limited to housing, transportation, insurance, food, healthcare and taxes (include property, income, and FICA taxes)

3. Disposable income (current monthly household income minus current monthly household expenses) $ /mo

4. After the purchase of this annuity, will you have sufficient income to meet or exceed your monthly expenses?. . . . . . . . . . . . c Yes c No

c. rePlAcement infOrmAtiOn Complete this section if there is an annuity-to-annuity replacement or a life-to-annuity replacement involved with this transaction.

• Allfieldsshouldbecompleted.

• Ifinformationisunknown,contactthecarrierfortheinformation.Ifinformationisnotapplicable,list“notapplicable”.

• If replacingmore thanone contract, please completea comparative chart for each replacement. If replacingmore than two contracts, completeadditional charts and both the owner(s) and producer(s) should sign and date the additional paperwork.

EXISTING CONTRACT # 1 EXISTING CONTRACT # 2 REPLACEMENT ANNUITY

Minimum Guaranteed Interest Rate % % %

Current Contract Value $ $ NA

Contract Surrender Value $ $ NA

Enhanced Death Benefit Value $ c N/A $ c N/A NA

Living Benefit Value $ c N/A $ c N/A NA

B. finAnciAl OBjectives And cOnsiderAtiOns (Continued)

f. Do you feel that you have been reasonably informed of the various features of the proposed annuity and understand the differences between your existing contract(s) and the proposed annuity, including but not limited to those set forth above in B6a-B6e? c Yes c No

If “Yes,” please explain.

e. Are there any potential tax penalties which may be incurred - in the event of a sale, exchange, surrender or annuitization of the annuity? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Yes c No

Page 3 of 4 Order #155669 09/01/2014TM: TSANBFIXED/INDEX

G. OtHer cOnsiderAtiOns (Note: Withdrawals may be subject to federal/state income tax and, if taken prior to age 59½, an additional 10% federal penalty tax.)

1. Federal income tax bracket: %

5. Do you anticipate any significant changes in your liquid assets or net worth during the surrender period? . . . . . . . . . . . . . . c Yes c No• If“Yes,”pleaseexplaintheanticipatedchanges (include, if possible, when you anticipate the changes to occur and the

approximate amount of the anticipated changes in income, living expenses or liquid assets).

6. Total value of all annuities (include the purchase of this annuity) $ • Whatisthetotalaccumulation/annuitizationvalueofallannuitiesyouownwiththisandothercompanies?

4. What percentage of your liquid assets does this annuity represent? (If liquid assets were used to purchase the annuity, divide annuity purchase amount by the amount in question 3 above to calculate this percentage. If liquid assets were not used to purchase this annuity, this response should be 0%.) %

2. Does the owner reside in a nursing home or assisted living facility? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Yes c No

3. After purchasing this annuity how much of your liquid assets will remain? $ • Includeassetsthatcanbeeasilyconvertedtocashwithoutpenalty,suchaschecking,savings,moneymarketaccounts,

and securities that can be sold without fees or penalty.• Donotincludeanypersonalbelongingsorpersonalpropertysuchasjewelry,furnishings,andvehicles.• Donotincludeanyassetsthatwillbeusedforthepurchaseoftheannuityoranyamountthatmaybewithdrawnfrom

the annuity for which you are applying.

f. finAnciAl infOrmAtiOn (Reverse Mortgage)

1. Have you ever had a reverse mortgage? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Yes c No

2. Do you currently have a reverse mortgage? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Yes c No

If you answered “Yes” to either of the questions above, please answer question 3 below.

3. Is the proposed annuity to be funded with proceeds from a reverse mortgage?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . c Yes c No

3. With the exception of any penalty-free withdrawals or required minimum distributions, do you expect to make a withdrawal, transfer or obtain a loan from this annuity before the end of the surrender charge period? . . . . . . . . . . . . . . . . . . . . . . c Yes c No

• If“Yes,”pleaseexplain. (Please provide an approximate date of when the money will be disbursed.)

1. Approximate household net worth $ • Totalcurrentvalueofhouseholdassets,includinginvestmentandlifeinsuranceholdingsandthepurchase payment for the annuity to be purchased, but excluding primary residence and any personal belongings or personal property such as jewelry, furnishings, and vehicles• Minustotaldebt(not including mortgage(s) or debt owed on the primary residence)

2. In purchasing this annuity, what percentage of your net worth (excluding your home) will be used? (Divide the annuity purchase amount by the amount in question 1 above to calculate this percentage.) %

e. finAnciAl infOrmAtiOn (Net Worth/Liquid Assets)

Page 4 of 4 Order #155669 09/01/2014TM: TSANBFIXED/INDEX

By signing below, I acknowledge that I believe that the annuity for which the owner(s) is applying is suitable to the financial needs and objectives of the owner(s). I base this belief on the information the owner(s) provided and on everything I know at this time. In addition, I have verified the identity of the owner(s) and believe that the identity information the owner(s) provided to me is true and accurate.

i. PrOducer AcknOwledGement

Producer Signature Date

2. (Must be completed.) The basis for my recommendation to purchase the proposed annuity is as follows:

1. I have known the owner(s) for: c 1 year or less c 1 to 3 years c 3+ years

H. Owner AcknOwledGement

By signing below, i understand that if i take money out of this annuity in excess of the penalty-free withdrawal amount that i will incur a surrender charge. I acknowledge that I reviewed the product-specific disclosure form with my producer and that I understand the costs and features of the annuity I am purchasing. In addition, I acknowledge the information I provided is complete and accurate to the best of my knowledge. I further acknowledge that neither ReliaStar Life Insurance Company nor its representatives offer legal or tax advice. I have been advised to consult my personal tax adviser or lawyer with any questions or concerns. I believe the annuity I am applying for is suitable based on my insurance needs and financial objectives.

Owner Signature Date Joint Owner Signature (If applicable) Date

The Company will not be in a position to review the suitability of this transaction should I choose either of the following options and I am therefore potentially waiving the protection afforded to me by any state laws or regulations regarding the suitability of this purchase. If you have provided the requested information above, do not check either box below.c I have chosen NOT to provide this information at this time.c I have chosen to provide LIMITED information at this time.

If there is any additional relevant information the producer should know before making a final recommendation (i.e., expected major life changes, beneficiary needs, anticipated future changes in income and expenses, etc.), please explain.