Death Claims
Waiver of Premium Claims
Accelerated Benefit Claims
Accident Claims
Total and Permanent Disability claims (NY Only)
Disability Income Claims
Critical Illness Claims
Administration Forms

ACCIDENT CLAIMS

There are different types of Accident Insurance and Accidental Death & Dismemberment (AD&D) coverages available. Please verify what coverage is available under your group policy, if any, before selecting from the claim forms below.


Accident Claims - Accident Insurance only, not under AD&D plans
Please distribute the claim form to the insured. The Consumer Privacy Notice is attached. To submit a claim under the Off Job Accident Disability Income Rider, you will also need to complete and sign the Employer's Statement (section 5) on page 3.

Accident Claim Form Number
Accident Claim (with Consumer Privacy Notice 47316b attached) for certificates issued by ReliaStar Life Insurance Company 139074 (rev 6/07)
Accident Claim (with Consumer Privacy Notice 47316b attached) for certificates issued by ReliaStar Life Insurance Company of New York 149256 (4/08)


Wellness Benefit Rider Claims - Accident Insurance only, not under AD&D plans
Please distribute the claim form to the insured. The Consumer Privacy Notice is attached.

Wellness Benefit Claim Form Number
Wellness Benefit Rider Claim (with Consumer Privacy Notice 47316b attached) for certificates issued by ReliaStar Life Insurance Company 150342 (7/08)


Dismemberment Claims - AD&D only, not under Accident Insurance
Please distribute the following forms to the employee/insured. Be sure to complete and sign the Employer's sections of the claim form before distributing.
1) Dismemberment Claim form
2) Attending Physician's Statement of Dismemberment
3) Authorization for Release of Health-Related Information
4) Consumer Privacy Notice

Dismemberment Claim Form Number
Claim form for group policies issued in New York 124001 (rev 1/07)
Claim form for group policies issued in all other states 47987e (116486)

Attending Physician's Statement of Dismemberment
Form Number
Attending Physician's Statement of Dismemberment (all states) 47088d (116150)

Authorization for Release of Health-Related Information
Form Number
Authorization for Release of Health-Related Information 127182 (rev 10/04)

Consumer Privacy Notice Form Number
Consumer Privacy Notice 47316b (116249)
Accidental Dismemberment Claims