Accident Insurance Claims (Non-Compass)

There are different types of Accident Insurance coverage available. Please verify what coverage is available under your group policy, if any, before selecting from the claim forms below.

Accident Insurance Claims (Non-Compass)

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.

Form Name Form Number

Accident Insurance Claim (with Consumer Privacy Notice 47316c attached) for certificates issued by ReliaStar Life Insurance Company

139074 (rev 9/01/2014)

Accident Insurance Claim (with Consumer Privacy Notice 47316c attached) for certificates issued by ReliaStar Life Insurance Company of New York

149256 (rev 9/01/2014)

Wellness Benefit Rider Claims

Please distribute the claim form to the insured.  The Consumer Privacy Notice is attached.

Form Name Form Number

Wellness Benefit Rider Claim (with Consumer Privacy Notice 47316c attached) for certificates issued by ReliaStar Life Insurance Company

165760 (rev 9/01/2014)

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.