Waiver of Premium Claims

Not all group life policies have this option - check your certificate. There may be eligibility limits for this benefit (i.e. the employee usually has to be under age 60 to apply). 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

45193h (115812) (rev 9/01/14)

Claim form for group policies issued in all other states

428571l (115591) (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.