Accidental Death and Dismemberment (AD&D) 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. Accidental Dismemberment Claim form
  2. Attending Physician's Statement of Dismemberment
  3. Authorization for Release of Health-Related Information
  4. Consumer Privacy Notice
Form Name Form Number

Accidental Dismemberment Claim for group policies issued in New York

124001 (rev 9/01/14)

Accidental Dismemberment Claim for group policies issued in all other states

47987g (116486) (rev 9/01/14)

Attending Physician's Statement of Dismemberment (all states)

47088f (116150) (rev 9/01/14)

Authorization for Release of Health-Related Information all states

127182 (rev 9/01/14)

Consumer Privacy Notice

47316c (116249) (rev 5/01/14)

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.