Authorization for Electronic Funds Transfer

(Disability Income Insurance)

Not all plans have this option: contact your Disability Benefit Specialist for more information.

Distribute this form to disabled employees who want to set up direct deposit for payment of their Disability Income benefits.

Form Name Form Number

Authorization for Electronic Funds Transfer for group policies issued by ReliaStar Life Insurance Company

47996d (116488) (rev 9/01/14)

Authorization for Electronic Funds Transfer for group policies issued by ReliaStar Life Insurance Company of New York

49258b (117480) (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.