Voluntary Disability Income Claims

(marketed as Horizon or Premier Disability Income)

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

  1. Employee's Statement (with Authorization for Release of Health-Related Information)
  2. Attending Physician's Statement
  3. Consumer Privacy Notice

You, the employer, need to complete and sign the Claim Notice Employer's Statement.

All completed forms need to be returned to the insurance company at the address shown at the top of each form.

Employer Forms Form Number

Claim Notice Employer's Statement for certificates issued in all states other than New York

49817d (160500) (rev 9/01/14)

Claim Notice Employer's Statement for certificates issued in New York

49817NYd
160501 (rev 9/01/14)

Employee Forms Form Number

Employee's Statement (with Authorization 127182 attached) for certificates issued in all states other than New York

160502 (rev 9/01/14)

Employee's Statement (with Authorization 127182 attached) for certificates issued in New York

160503 (rev 9/01/14)

Attending Physician's Statement for certificates issued in all states other than New York

160504 (rev 9/01/14)

Attending Physician's Statement for certificates issued in New York

160505 (rev 9/01/2014)

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.