Exhibit 24(b)(5.3):  Variable annuity Application (164194 (10/14)(NRR)

VARIABLE ANNUITY APPLICATION
ReliaStar Life Insurance Company		[VOYA LOGO]
(the “Company”)
[A member of the VoyaTM family of companies]
[Home Office: 20 Washington Avenue South, Minneapolis, MN 55401-1900
Customer Service Administrative Address: PO Box 5050, Minot, ND 58702-5050]
IMPORTANT NOTICES
[Below are notices that apply only in certain states. Please read the following carefully to see if any apply in your state.
California Reg. 789.8: The sale or liquidation of any stock, bond, IRA, certificate of deposit, mutual fund, annuity, or other asset to
fund the purchase of this product may have tax consequences, early withdrawal penalties, or other costs or penalties as a result
of the sale or liquidation. You or your agent may wish to consult independent legal or financial advice before selling or liquidating
any assets and prior to the purchase of any life or annuity products being solicited, offered for sale, or sold.
Illinois Civil Union Notice: Effective June 1, 2011, for contracts issued in Illinois, the Company is in compliance with the Illinois
Religious Freedom Protection and Civil Union Act (Public Act 96-1513) to the extent allowed under Federal Law.
Illinois Public Act 96-1513 (“The Act”) provides that civil union couples as defined in the Act are entitled to the same legal obligations,
responsibilities, protections and benefits that are afforded or recognized by the laws of Illinois to spouses in a marriage.
Under Federal Law, however, certain favorable federal tax treatment available to spouses that are married is not available to
partners in a civil union, e.g. spousal continuation. If you are a civil union partner, we suggest that you consult with a tax advisor
prior to purchasing an annuity contract, such as this one, which provides spousal benefits.
Oklahoma: WARNING - Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for
the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Washington: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the
purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.
Washington, DC: WARNING - It is a crime to provide false or misleading information to an insurer for the purpose of defrauding
the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits
if false information materially related to a claim was provided by the applicants.
Arkansas and Tennessee: Any person who knowingly and with intent to injure, defraud or deceive any insurance company,
submits an application for insurance containing any materially false, incomplete, or misleading information, or conceals for
the purpose of misleading, any material fact, is guilty of insurance fraud, which is a crime and in certain states, a felony.
Penalties may include imprisonment, fine, denial of benefits, or civil damages.]
MAILING INSTRUCTIONS
[Make checks payable to: ReliaStar Life Insurance Company
If sending only an application, mail to:
Standard Mail:	Overnight Delivery:
ReliaStar Life Insurance Company	ReliaStar Life Insurance Company
PO Box 5050	2000 21st Ave. NW
Minot, ND 58702-5050	Minot, ND 58703
If sending both check and application, mail to:
Standard Mail:	Overnight Delivery:
ReliaStar Life Insurance Company	ReliaStar Life Insurance Company
PO Box 2280	Box 2280
New York, NY 10116	4 Chase Metrotech Center, 7th Floor
	New York, NY 11245]
164194(10/14)(NRR)	Page 1 of 6 - Incomplete without all pages.	Order #169189 01/01/2015
		TM: TSANBVAR/INDEX

VARIABLE ANNUITY APPLICATION
ReliaStar Life Insurance Company			[VOYA LOGO]
(the “Company”)
[A member of the VoyaTM family of companies]
[Home Office: 20 Washington Avenue South, Minneapolis, MN 55401-1900
Customer Service Administrative Address: PO Box 5050, Minot, ND 58702-5050]
1. ANNUITANT (Must be the same as Owner for TSA, IRA, Roth IRA, or Roth 403(b).)
Name		Birth Date
Street Address (Required)		SSN (Required)
PO Box (if applicable)		Sex ¨ Male	¨ Female
City		Phone
State	ZIP	Alternate Phone
Joint Annuitant (Does not apply to TSA, IRA, Roth IRA or 457.)
Name		Birth Date
Street Address (Required)		SSN (Required)
PO Box (if applicable)		Sex ¨ Male	¨ Female
City		Phone
State	ZIP	Alternate Phone
2. OWNER (Complete this section if applicable to selected contract and owner is different than Annuitant. If owner is
different from annuitant, also provide owner’s signature in section 12 of application. If a non-natural owner, please provide
proper documents; e.g., first and last page of trust, corporate resolution, etc.)
Name		Birth Date
Street Address (Required)		SSN/TIN (Required)
PO Box (if applicable)		Sex ¨ Male	¨ Female
City		Phone
State	ZIP	Alternate Phone
Joint Owner (Does not apply to TSA, IRA, Roth IRA or 457.)
Name		Birth Date
Street Address (Required)		SSN/TIN (Required)
PO Box (if applicable)		Sex ¨ Male	¨ Female
City		Phone
State	ZIP	Alternate Phone
164194(10/14)(NRR)	Page 2 of 6 - Incomplete without all pages.		Order #169189 01/01/2015
			TM: TSANBVAR/INDEX

3. BENEFICIARY(S) (Must be completed unless the annuity is part of a Plan subject to the Employee Retirement Income
Security Act of 1974 (ERISA). Beneficiaries of ERISA plans must be designated using the [Beneficiary Election/Change Request
- ERISA form.)]
Beneficiary proceeds will be split equally if no percentages are provided.
Note: For Non-qualified contracts, if there are Joint Owners, death proceeds are paid first to the surviving Joint Owner.
Primary Beneficiary
Name					Birth Date				Percent	%
SSN/TIN			Sex	¨ Male	¨ Female		Relationship to Annuitant
Address
City		State			ZIP				Phone
¨ Primary	¨ Contingent Beneficiary
Name					Birth Date				Percent	%
SSN/TIN			Sex	¨ Male	¨ Female		Relationship to Annuitant
Address
City		State			ZIP				Phone
¨ Primary	¨ Contingent Beneficiary
Name					Birth Date				Percent	%
SSN/TIN			Sex	¨ Male	¨ Female		Relationship to Annuitant
Address
City		State			ZIP				Phone
¨ Primary	¨ Contingent Beneficiary
Name					Birth Date				Percent	%
SSN/TIN			Sex	¨ Male	¨ Female		Relationship to Annuitant
Address
City		State			ZIP				Phone
Use the space in section 4 if you need to list more Beneficiaries. Be sure to designate whether additional Beneficiaries
are Primary or Contingent.
4. SPECIAL INSTRUCTIONS (If necessary, attach a sheet signed and dated by the owner(s) containing any additional instructions.)
5. PRODUCT SELECTION AND PLAN TYPE
All products and plan types may not be available in all states.
Place a check mark in the box corresponding to your product and plan type selection.
[Product/Plan Type		TSA	Roth 403(b)		457	Non-Qualified		IRA	SEP-IRA	Roth IRA
Voya Advantage Century										]
[If you have elected a Roth 403(b), indicate the first year you made a contribution to any previously established Roth 403(b) account
in your employer’s plan: ____________. If no year is provided, we will use the first year a payment is applied to this contract.]
164194(10/14)(NRR)			Page 3 of 6 - Incomplete without all pages.						Order #169189 01/01/2015
										TM: TSANBVAR/INDEX

6. DEATH BENEFIT OPTION
[One Year Step Up Death Benefit Option (Not available in all states.)
A standard death benefit is available with the contract. Please check below if you want the optional One Year Step Up Death
Benefit. See the prospectus for details. A death benefit option may not be terminated or changed.
¨ One Year Step Up Death Benefit (This will replace the standard death benefit.)]
7. REPLACEMENT (Must be completed.)
Will the annuity contract applied for replace any existing life insurance policy or annuity contract? ¨ Yes ¨ No
If “Yes”, please complete and return with this application a copy of your state’s replacement form, as provided by your insurance
producer.
8. EMPLOYER (Must be completed for TSA, Roth 403(b), and 457.)
Employer Name
Contact Name				Phone
Mailing Address
City				State	ZIP
9. PAYMENT AND BILLING INFORMATION (Select all options that apply.)
Initial Purchase Payment will be made by:
¨ Check (attached) $			¨ Other Source of Payment		$
Applicable Tax Year (IRA/Roth IRA only):			Describe:
¨ Exchange/Transfer/Rollover
Purchase Payments (The Company does not accept purchase payments using money orders for amounts over $5,000 and
may reject payments made by cashier’s check, bank drafts, bank checks and treasurer’s checks. All purchase payment checks
must be made payable to ReliaStar Life Insurance Company.)
¨ Monthly Electronic Fund Transfer (EFT). (Does not apply to TSA or 457. Attach EFT request.)
The purchase payments are:	Payment Amount	X	# of Payments =	Annual Purchase Payment 1st Remittance Date
1. ¨ Employee Contributions	1.			$
2. ¨ Employer Contributions	2.			$
	Total Annual Purchase Payment (12-month			$
	Period Only)
A Salary Reduction Agreement or Amendment to Employment Contract is required for 403(b), Roth 403(b) and 457 plans.
10. AUTOMATIC TELEPHONE PRIVILEGES
I understand that unless I decline, telephone privileges are automatically provided to me, my insurance producer/registered
representative, and his/her assistant. After an authorized person has discussed any changes with me, telephone privileges
allow the authorized person to call the Company to perform certain transactions as specified in the current prospectus. The
Company may use procedures to ensure instructions received by telephone are genuine, such as requiring forms of personal
identification and tape recording phone calls. The Company and its distributor will not be liable for any loss, damage, costs or
expenses incurred in acting on telephone instructions reasonably believed to be authentic. I understand that if I do not want to
authorize telephone privileges, I must indicate below. I also understand that once granted, such privileges can be revoked only
upon receipt of signed, written instructions at the Company.
¨ I do not want telephone privileges for myself or my insurance producer/registered representative and/or the registered
representative’s assistant.
¨ I do not want telephone privileges granted to my insurance producer/registered representative and/or the registered
representative’s assistant.
164194(10/14)(NRR)	Page 4 of 6 - Incomplete without all pages.				Order #169189 01/01/2015
					TM: TSANBVAR/INDEX

11. ALLOCATING INITIAL PURCHASE PAYMENTS TO THE INVESTMENT OPTIONS
[This application must be accompanied by a copy of the Variable Annuities Portfolio Allocation and Transfer Request. We will
allocate your purchase payments among the investment options you select on the Variable Annuities Portfolio Allocation and
Transfer Request. The proposed Owner understands that if he/she is entitled to a refund of the purchase payments made upon
the revocation of a contract during the free look period, then all purchase payments made until five days after the end of the
free look period will be allocated to the Money Market subaccount identified in the prospectus, and then transferred to the Fixed
Account(s) and/or the subaccounts as designated on the Variable Annuities Portfolio Allocation and Transfer Request.]
12. APPLICANT SIGNATURES AND ACKNOWLEDGEMENTS (Please read carefully and sign below.)
Important Information: To help the government fight the funding for terrorism and money laundering activities, federal law
requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account.
What this means to you: When you apply for an annuity, we will ask for your name, address, date of birth, and other information
that will allow us to identify you. We may also ask to see your driver’s license or other identifying documents.
I agree that, to the best of my knowledge and belief, all statements and answers in this form are complete and true
and may be relied upon in determining whether to issue the applied for variable annuity. Only the owner and ReliaStar
Life Insurance Company have the authority to modify this form. I also represent that the Social Security Number or Tax
Identification Number shown on this form is correct.
Make checks payable ONLY to ReliaStar Life Insurance Company. Do not make checks payable to the insurance producer,
an agency or another company. Only the President, Vice President, or Secretary of ReliaStar Life Insurance Company
may modify, discharge or waive any of its rights under the contract.
Variable Annuities and the underlying series shares or securities which fund them are not insured by the FDIC or any
other agency. They are not deposits or other obligations of any bank and are not bank guaranteed. They are also subject
to market fluctuation, investment risk and possible loss of principal invested.
Annuity payouts and contract values under a variable annuity are variable and are not guaranteed as to fixed dollar
amounts.
I understand that when based on the investment experience of the Separate Account, the variable annuity cash surrender
values may increase or decrease on any day and that no minimum value is guaranteed. The variable annuity applied for
is in accord with my anticipated financial objectives.
ACKNOWLEDGEMENT OF PROSPECTUS RECEIPT
By signing below, I acknowledge receipt of the Variable Annuity Contract Prospectus.
ACKNOWLEDGEMENT OF 403(b) WITHDRAWAL RESTRICTIONS
For employees purchasing a 403(b) contract: I understand the Internal Revenue Code restrictions on withdrawals
from a 403(b) tax-deferred annuity, which generally prohibit withdrawals prior to my death, disability, attainment
of age 59 1/2, severance from employment or financial hardship. More specific information about these restrictions
can be found in the Withdrawal (redemption) section of the Prospectus or the Withdrawals section of the contract. I
understand these restrictions do not apply to exchanges to other investment alternatives under my Employer’s 403(b)
Plan, transfers made to another Employer’s 403(b) plan or transfers made to a governmental defined benefit plan to
purchase service credit unless further restricted by my Employer’s 403(b) written plan.
Signed at (Both city & state required)	Date (Required)
Annuitant Signature
Joint Annuitant Signature (if applicable)
Owner Signature (if different from Annuitant)	Title
Joint Owner Signature (if applicable)
164194(10/14)(NRR)	Page 5 of 6 - Incomplete without all pages.	Order #169189 01/01/2015
		TM: TSANBVAR/INDEX

13. INSURANCE PRODUCER INFORMATION AND SIGNATURE
To your knowledge, will the annuity contract applied for replace any existing life insurance policy or annuity contract?
¨ Yes ¨ No
If “Yes”, please complete and return with this application a copy of your state’s replacement form.
Customer Identification (Choose one.)
¨ I certify that I personally met with the proposed owner(s) and reviewed government issued identification documents. To the
best of my knowledge it accurately reflects the identity of the proposed owner(s).
¨ I was unable to personally review the customer’s identification documents for the reason stated below. I certify that, to the
best of my knowledge, the information provided by the owner(s) is true and accurate.
Reason
Note: Failure to review the identification documents may delay the application process. The insurance producer or owner may be
contacted to provide additional information to validate the identity above.
I understand that misrepresentations in connection with this or other certifications in the Company’s application documents may
result in disciplinary action, termination, civil action, or prosecution for violation of state or federal criminal laws.
[Compensation Alternative (Choose one. The insurance producer is responsible for selecting the commission option desired.
Commission options may differ by product; refer to the compensation schedule or internal exchange guidelines compensation grid
for a description of the available options. If no option is selected, we will use the default option as it appears on your compensation
schedule.)
¨ Option A ¨ Option B	¨ Option D ¨ Option I	¨ Other	]
Note: All insurance producers must sign below if compensation will be split. Compensation will be split equally if no percentages
are indicated. Partial percentages will be rounded up. Insurance producer #1 will be given the highest percentage in the case of
unequal percentages. Insurance producer #1 will receive all correspondence regarding the contract.
By signing below you certify: 1) that you have truly and accurately recorded on the application the information provided by the
applicant, 2) any sales material was shown to the applicant and a copy was left with the applicant, 3) you used only insurer-
approved sales material, 4) you have not made statements that differ from the sales material, and 5) no promises were made about
the future value of any contract elements that are not guaranteed. (This includes any expected future index gains that may apply
to this contract.)
Insurance Producer #1
Name (Print)		Signature
Insurance Producer #	Insurance Producer Profile Code1		Split (Complete even if 100%.)		%
Insurance Producer #2
Name (Print)		Signature
Insurance Producer #	Insurance Producer Profile Code1			Split	%
Insurance Producer #3
Name (Print)		Signature
Insurance Producer #	Insurance Producer Profile Code1			Split	%
1 If not provided, we will default to an “as earned” profile code.
BROKER/DEALER USE ONLY (Not to be completed by insurance producer.)
Dealer Name	Branch Office			Dealer Symbol
Authorized Signature
164194(10/14)(NRR)	Page 6 of 6 - Incomplete without all pages.			Order #169189 01/01/2015
				TM: TSANBVAR/INDEX