Fillable Evidence Of Insurability Form (Page 4 of 4) in pdf

CONSUMER PRIVACY NOTICE AND

INSURANCE INFORMATION PRACTICES NOTICE

ReliaStar Life Insurance Company, Minneapolis, MN

ReliaStar Life Insurance Company of New York, Woodbury, NY

Members of the Voya family of companies

We are pleased to provide you with information regarding your application or claim. This information is provided to you in accordance with legislation enacted

in your state. You may also receive other privacy notices from us or from our affiliated companies. Please keep this notice and a copy of the completed

application or claim form for your records.

Our Underwriting Procedures

For certain types of coverage, we underwrite your request to determine if you are eligible for the coverage you requested. We review all of the information

in the application, and, if necessary, confirm or add to this information in the ways described in this notice. In the event of an adverse underwriting decision,

we will provide you with the specific reason for the decision in writing.

Privacy and Information Practices

Collecting Information

Your application or claim form is our main source of information. But we may:

- Ask you to have a physical exam, an EKG and/or a blood profile, etc.

- Ask physicians, hospitals, or other health care providers to confirm or add to the information you have given us. The types of information we may ask for are

described on the authorization form you will be asked to sign. If you want a copy of this form, it will be given to you for your records.

- Obtain information from MIB, Inc., formerly known as the Medical Information Bureau. See “Notice Regarding MIB, Inc.” below.

- Seek information from other companies you have applied to for insurance.

- Ask you for additional information through use of a written request.

Notice Regarding Consumer Reports

Insurance companies commonly ask an outside source to verify and add to the information given in an application. Consumer reports are used to help us

decide if you are eligible for the insurance you have applied for. The report deals with your mode of living, character, general reputation, and such personal

items as your health, job, and finances. It may include information on the following: your marital status, past and present employment record, job duties,

driving record, avocation, health history, use of alcohol and drugs, and hazardous sports activities. The agency may get information in these ways: from public

records, and by contacting you, members of your family, business associates and employers, financial sources, friends, or others you know. This information

will not be used to determine your sexual orientation. You can request that the agency interview you in connection with the preparation of the report. If the

report affects your application as requested, we will notify you and provide you with the name and address of the reporting firm.

We use the report only to be sure that each application is evaluated on a fair basis. We will not reveal any of the information we obtain to your friends or

associates. We may reveal the information we obtain to other companies or entities affiliated with us. The information may be kept by the consumer reporting

agency; it may also later be given to others who have a legitimate need for these reports. It will be given only to the extent permitted by these laws: the

Federal Fair Credit Reporting Act as amended by the Consumer Credit Reporting Reform Act of 1996; your state’s Fair Credit Reporting Act, if any; or your

state’s Insurance Information and Privacy Protection Act, if any. If you wish, we will send you the name, address and phone number of any agency we ask to

prepare a consumer report about you. The agency will give you a copy of the report if you ask for one and give proper identification.

Information Use

We will use the information only for business purposes arising from the relationship you have with us.

Information Maintenance and Disclosure

We treat the information we have about you as confidential. The authorization form that you have been asked to complete will permit us to send the

information to our affiliates and to MIB, our reinsurers, employees, contractors, or other organizations that process transactions concerning coverage you

have with us or our affiliates, and to other life insurance companies to whom you may apply for life or health insurance or to whom a claim for benefits may

be submitted. In certain circumstances, the information we have about you may be disclosed to third parties without your specific permission.

Access to Information

If you request it in writing, we will send you a copy of the relevant information we obtain about you in connection with your request for coverage or an

adverse underwriting decision. Medical information, however, will only be disclosed through the attending licensed physician unless state law provides

otherwise. If you feel that any of the information in our file is not correct or is incomplete, we will review it. If we agree with you, we will make the corrections.

If we do not agree with you, you may file a short statement of dispute with us. Your statement will be included any time we disclose this information to anyone.

We will not send you information we collect in expectation of or in connection with any claim or civil or criminal proceeding.

Notice Regarding MIB, Inc.

We or our reinsurers may make brief reports to MIB. The reports will include the factors that affect the insurability of any person for whom coverage is being

requested. MIB is a nonprofit organization of life insurance companies. It operates an information exchange for its members. If you apply to some other

member company for life or health coverage, or send in a claim for benefits, MIB may supply that company with any information in its file. If you ask, MIB will

arrange to disclose to you the information it has about you in its file. If you question the accuracy of the information in MIB’s file, you may contact MIB and

ask them to correct it as provided in the Fair Credit Reporting Act. The address of MIB’s information office is 50 Braintree Hill Park, Suite 400, Braintree, MA

02184-8734. MIB’s phone number is 866-692-6901 (TTY 866 346-3642). We may also release information in our files to other life insurance companies to

whom you may apply for life or health insurance or to whom a claim for benefits may be submitted.

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Order #116249 05/01/2014