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

CRITICAL ILLNESS AND WELLNESS BENEFIT CLAIMS

To submit a claim, you need to distribute the following forms to the insured claimant:
1) Claim form
2) Attending Physician's Statement of Critical Illness (not used for Wellness claims)
3) Authorization to Release Information (not used for Wellness
claims)
4) Consumer Privacy Notice

Claim Form (ReliaStar Life Insurance Company only)
Form Number
Critical Illness Claim 126173 (rev 08/07)
Wellness Benefit Claim 126172 (rev 06/07)

Attending Physician's Statement of Critical Illness
Form Number
Attending Physician's Statement of Critical Illness 126171 (rev 8/07)

Authorization to Release Information Form Number
Authorization 132542 (rev 8/08)

Consumer Privacy Notice Form Number
Consumer Privacy Notice 47316b (116249)