Long Term Disability Conversion Information Request Form

(Monthly Income Benefits)

  • Not all groups have this option: check your certificate.
  • Use this form when employee long term disability coverage (monthly income benefits) becomes eligible for conversion.
  • Check your certificate for the Conditions for Conversion. Residents of these states are NOT eligible for conversion: FL, IN, LA, MI, NY, OR, SD and WV.
  • Remember to complete the Employer's section of the form and attach a current Schedule of Benefits before distributing the form to the employee.
Form Name Form Number

LTD Conversion Information Request Form

43736f (115671) (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.