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Claim Forms

For your convenience, we now have available a Claims Center where you can find claims forms or begin filing a claim.

Administrative Forms

The forms provided here are standard Administration forms. If any form you need is listed as "TBD" then please contact your Account Representative to order a paper supply as indicated in your Administration Manual. Any Enrollment forms and Evidence of Insurability forms must be obtained through your local Account Representative.

Request for Change form+

Use this form to process changes such as name or address, and coverage reductions or terminations.

Amendment to Original Application (Life Insurance)+

(Life Insurance)

Use this form if the insured person needs to switch his/her status to "non-tobacco user" for the purpose of premium rates. Not available on all plans.

Form Name
Number/
Last Revised
Beneficiary Designation form (Life Insurance)+

(Life Insurance)

The completed form must be sent to the insurer for approval (along with copies of all enrollment forms, beneficiary changes, and absolute assignments) in any of the following situations:

  • If the designation differs from the examples on the reverse side of the form,
  • If the coverage has been assigned,
  • If the previous beneficiary was irrevocable, or
  • If the insurer maintains all the beneficiary designation records for your plan (including all individual policies).
Absolute Assignment of Life insurance form+

If the current owner of life insurance wants to assign ownership of coverage, then the current owner and the new owner must complete and sign this form.

The completed form must be sent to the insurer for the registrar's signature, along with copies of all enrollment forms, beneficiary designations and past assignments.

Statement of Intent (Life Insurance)+

(Life Insurance)

If group life insurance was assigned under a prior group policy, then in order to continue the assignment under the new Group Policy the insured person and the owner must complete and sign a Statement of Intent form.

The completed form must be sent to the insurer for approval, along with copies of all enrollment forms, beneficiary designations and the prior absolute assignment.

Life Conversion Information Request form+
  • Use this form when employee and/or dependent life coverage becomes eligible for conversion.
  • Check your certificate for the Conditions for Conversion.
  • Remember to complete the Employer's section before distributing the form to the insured person(s).
  • If ownership of employee coverage is assigned, the form must be distributed to the owner instead of to the insured person.
  • NOTE: There are time limits that pertain to your distribution of this form and the recipient's return of the completed form to the insurance company. See your certificate for details.
  • NOTE: This form must be provided each time life coverage becomes eligible for conversion, even if the insured person may also be eligible for other benefits under the policy.
Term Life Coverage Continuation Request form+
  • This is used ONLY for groups that have the optional portability benefit for life coverage. Check your certificate for details before distributing this form.
  • Remember to complete the Employer sections of the form before distributing the form to the insured person.
  • If ownership of coverage is assigned, the form must be distributed to the owner instead of to the insured person.
  • NOTE: There are time limits that pertain to your distribution of this form and the recipient's return of the completed form to the insurance company. See your certificate for details.
  • NOTE: The owner of coverage must also receive the Conversion Information Request Form along with this form.
Long Term Disability Income 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
Number/
Last Revised
Authorization for Electronic Funds Transfer (Disability Income Insurance)+

(Disability Income Insurance)

Not all plans have this option: contact your Disability Benefit Specialist for more information.

Distribute this form to disabled employees who want to set up direct deposit for payment of their Disability Income benefits.

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.