Accelerated Benefit Claims

Not all group life policies have this option - check your certificate. Remember to complete any applicable Employer's section(s) before distributing forms to employees/insureds.

To submit a claim, you need to distribute the following forms to the employee/insured:

  1. Claim form
  2. Attending Physician's Statement of Terminal Condition
  3. Authorization for Release of Health-Related Information
  4. Consumer Privacy Notice
  5. Disclosure Statement
Form Name Form Number

Claim form for group policies issued in New Jersey

121585 (rev 9/01/14)

Claim form for group policies issued in New York

121488 (rev 9/01/14)

Claim form for group policies issued in all other states

121583 (rev 9/01/14)

Attending Physician's Statement of Terminal Condition (all states)

121489 (rev 9/01/14)

Authorization for Release of Health-Related Information

127182 (rev 9/01/14)

Consumer Privacy Notice

47316c (116249) (rev 9/01/14)

Disclosure Statements Form Number

Disclosure Statement for group policies issued in Connecticut

44539CT (rev 9/01/14)

Disclosure Statement for group policies issued in Illinois

44539IL (rev 9/01/14)

Disclosure Statement for group policies issued in Kentucky

44539KY (rev 9/01/14) +159144

Disclosure Statement for group policies issued in Massachusetts

43734c (rev 9/01/14)

Disclosure Statement for group policies issued in Montana

44539MT (rev 9/01/14)

Disclosure Statement for group policies issued in Oregon

44539OR (rev 9/01/14)

+ 154673

Disclosure Statement for group policies issued in Washington

44539WA (rev 9/01/14)

+ page 2

Disclosure Statement for group policies issued in ALL OTHER STATES except New York

44539 (rev 9/01/14)

Disclosure Statement for individual portable policies issued to individuals in Montana

44539MT (rev 9/01/2014)

Disclosure Statement for individual portable policies issued to individuals in Washington

44539WA (rev 9/01/14) + page 2

Disclosure Statement for individual portable policies issued to individuals in Florida, Michigan, Minnesota, South Dakota, Utah or Vermont

44539 (rev 9/01/14)

Voya™ Employee Benefits insurance products and services in the U.S. are provided by ReliaStar Life Insurance Company (Minneapolis, MN) and ReliaStar Life Insurance Company of New York (Woodbury, NY). Within the State of New York, only ReliaStar Life Insurance Company of New York is admitted, and its products issued. Both are members of the Voya™ family of companies. Product availability and specific provisions may vary by state. Each insurer is solely responsible for the financial obligations under the policies or contracts it issues.