Hospital Confinement Indemnity Claims

Please distribute the following forms to the insured.

  1. Compass Hospital Confinement Indemnity Claim - Employee Form. The Consumer Privacy Notice is attached.
  2. Attending Physician's Statement of Hospital Confinement Indemnity
  3. Authorization to Release Information
  4. Hospital Confinement Indemnity Claim – Employer form.
    Note: If the employer has submitted enrollment data electronically, this form does not need to be completed.
Form Name Form Number

Compass Hospital Confinement Indemnity Claim - Employee (with Consumer Privacy Notice 47316c attached)for group policies issued in all states except New York

167313 (rev 9/01/14)

Attending Physician's Statement of Hospital Confinement Indemnity for group policies issued in all states except New York

167314 (rev 9/01/14)

Authorization to Release Information

132542 (rev 9/01/14)

Hospital Confinement Indemnity Claim - Employer (with Consumer Privacy Notice 47316c attached) for group policies issued in all states except New York

167546 (rev 9/01/14)

Wellness Benefit Claim

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

Form Name Form Number

Wellness Benefit Rider Claim – Employee (with Consumer Privacy Notice 47316c attached) for group policies issued in all states except New York

165760 (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.