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Claim Forms

Benefits administration is a big job at any size company. To make things easier for your human resources team, we maintain an online Forms Library for easy access to the forms you need. With access to these forms, you can always be sure to have the correct paperwork for the correct situation.

  • Note that forms on this site are standard Claim and Administration forms. Any Enrollment forms and Evidence of Insurability forms must be obtained through your local Account Representative.
  • When printing multiple-page forms, please make every attempt to print these as 2-sided pages.
  • Remember to complete any applicable Employer's section(s) before distributing forms to employees.
  • Please contact your local Account Representative for any questions you may have regarding further usage of these forms.
Death Claims+

Remember to complete any applicable Employer's section(s) before distributing forms to beneficiaries.

Frequently Asked Questions for Death Claims

When you provide the claim form to the beneficiary(ies) to sign, you must also provide the Voya®  Personal Transition Account Supplemental Contract to each beneficiary. Not applicable to beneficiaries residing in Alaska, Illinois, Kansas, North Carolina, or Nevada.

If a trust is named as the beneficiary, the Trust Verification form must be completed by the trustee.

 

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
Accelerated Benefit Claims+

Not all group life policies have this option - check your certificate. Remember to complete any applicable Employer's section(s) before distributing forms to employees/insureds.

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

  1. Claim form
  2. Attending Physician's Statement of Terminal Condition
  3. Authorization for Release of Health-Related Information
  4. Consumer Privacy Notice
  5. Disclosure Statement
Form Name
Number/
Last Revised
Compass Accident Insurance Claims+

There are different types of Accident Insurance coverage available. Please verify what coverage is available under your group policy, if any, before selecting from the claim forms below.

Compass Accident Insurance Claims
Please distribute the claim form to the insured. The Consumer Privacy Notice is attached.

Note: If the employer has submitted enrollment data electronically, the Employer form below does not need to be completed.

Wellness Benefit Rider Claims
Please distribute the claim form to the insured.  The Consumer Privacy Notice is attached.

Accident Insurance Claims (Non-Compass)+

There are different types of Accident Insurance coverage available. Please verify what coverage is available under your group policy, if any, before selecting from the claim forms below.

Accident Insurance Claims (Non-Compass)
Please distribute the claim form to the insured. The Consumer Privacy Notice is attached. To submit a claim under the Off Job Accident Disability Income Rider, you will also need to complete and sign the Employer's Statement (section 5) on page 3.

Wellness Benefit Rider Claims
Please distribute the claim form to the insured.  The Consumer Privacy Notice is attached.

Accidental Death and Dismemberment (AD&D) Insurance Claims+

Many of our group plans provide for Accidental Death & Dismemberment (AD&D) Insurance coverage. Please verify what coverage is available under your group policy, if any, before selecting from the claim forms.

Please distribute the following forms to the employee/insured. Be sure to complete and sign the Employer's sections of the claim form before distributing.

  1. Accidental Dismemberment Claim form
  2. Attending Physician's Statement of Dismemberment
  3. Authorization for Release of Health-Related Information
  4. Consumer Privacy Notice
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
Short Term Disability Income Claims+

(Weekly Income Benefits)

To submit a claim, provide the following forms to the employee:

  1. Short Term Disability Claim Notice Employer's Statement/Employee's Statement
  2. Authorization for Release of Health-Related Information
  3. Short Term Disability Attending Physician's Statement of Impairment and Function
  4. Consumer Privacy Notice

The employee must return the claim form to you (the employer) with the Employee's Statement and Authorization to Release Information sections completed. He/she also must return the completed Attending Physician's Statement to you, and the separate Authorization for Release of Health-Related Information.

Complete the Employer's Statement section of the claim form and send all the documents to the insurance company at the address shown at the top of the claim form.

Temporary Disability Income (TDI) Claims – Hawaii Only+

(Hawaii ONLY)

A TDI claim must be filed within 90 days after commencement of the disability period.

Complete the Employer's Statement section of the claim form. Provide the claim form and Consumer Privacy Notice to the employee.

Form Name
Number/
Last Revised
Long-Term Disability Income Claims+

(Monthly Income Benefits)

Remember to complete any applicable Employer form(s) or section(s) before distributing forms to employees.

To submit a claim, you (the employer) need to complete the following forms:

  1. Long Term Disability Claim Notice Employer's Statement, and
  2. Long Term Disability Occupational Demands

The completed Occupational Demands form (with a copy of the employee's job description attached) needs to be provided to the employee along with the following forms:

  1. Disability Claim Filing Instructions
  2. Long Term Disability Employee's Statement
  3. Attending Physician's Statement of Impairment and Function
  4. Authorization for Release of Health-Related Information, and
  5. Consumer Privacy Notice
Voluntary Disability Income Claims (Horizon and Premier)+

(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.

Compass Critical Illness/Specified Disease Claims+

There are different types of Critical Illness Insurance coverage available. Please verify what coverage is available under your group policy, if any, before selecting from the claim forms. If you have any questions, please contact your employer.

Critical Illness Insurance* Claim
*known as Specified Disease Insurance in some states

Please distribute the following forms to the insured.

  1. Compass Critical Illness (or Specified Disease) Claim form. The Consumer Privacy Notice is attached
  2. Attending Physician's Statement of Compass Critical Illness (or Specified Disease)
  3. Authorization to Release Information
  4. Critical Illness (or Specified Disease) Claim – Employer form. Note: If the employer has submitted enrollment data electronically, this form does not need to be completed.

To submit a Wellness Benefit Rider Claim:
Please print the Critical Illness (or Specified Disease) Wellness Benefit Claim form below. The Consumer Privacy Notice is attached. Submit the completed and signed form to the address shown at the top of the form.

Form Name
Number/
Last Revised
Premier and Horizon Critical Illness/Specified Disease Claims+

There are different types of Critical Illness Insurance coverage available. Please verify what coverage is available under your group policy, if any, before selecting from the claim forms. If you have any questions, please contact your employer.

Critical Illness* Insurance Claim
*known as Specified Disease Insurance in some states

Please distribute the following forms to the insured.

  1. Critical Illness (or Specified Disease) Claim form. The Consumer Privacy Notice is attached
  2. Attending Physician's Statement of Critical Illness (or Specified Disease)
  3. Authorization to Release Information

To submit a Wellness Benefit Claim:
Please print the Critical Illness (or Specified Disease) Wellness Benefit Claim form below. The Consumer Privacy Notice is attached.

Submit the completed and signed form to the address shown at the top of the form.

Compass Hospital Confinement Indemnity Claims+

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.

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

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.