Total and Permanent Disability Claims (NY)

(New York ONLY)

There are time periods for applying for this benefit - check your policy and certificate. Remember to complete any applicable Employer's section(s) before distributing forms to employees.

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

  1. Claim form
  2. Attending Physician's Statement of Disability
  3. Authorization for Release of Health-Related Information
  4. Consumer Privacy Notice
Form Name Form Number

Claim form for group policies issued in New York

123985 (rev 9/01/14)

Attending Physician's Statement of Disability

44540i (115754) (rev 9/01/14)

Authorization for Release of Health-Related Information

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.