Accident Claims
There are different types of Accident Insurance and Accidental Death & Dismemberment (AD&D) coverages available. Please verify what coverage is available under your group policy, if any, before selecting from the claim forms below.
Accident Claims - Accident Insurance only, not under AD&D plans
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. If accident resulted in death the beneficiary must sign an IRS W-9 form.
| Form Name | Form Number |
|---|---|
Accident Claim (with Consumer Privacy Notice 47316c attached) for certificates issued by ReliaStar Life Insurance Company | 139074 (rev 11/08) |
Accident Claim (with Consumer Privacy Notice 47316c attached) for certificates issued by ReliaStar Life Insurance Company of New York | 149256 (11/08) |
IRS Form W-9 English version | Form W-9 (01/11) |
IRS Form W-9 Spanish version | Form W-9 (SP) (02/11) |
Wellness Benefit Rider Claims – Accident Insurance only, not under AD&D plans
Please distribute the claim form to the insured. The Consumer Privacy Notice is attached.
| Form Name | Form Number |
|---|---|
161609 (10/2011) | |
Accident Only - Wellness Benefit Rider Claim (with Consumer Privacy Notice 47316c attached) for certificates issued by ReliaStar Life Insurance Company | 150342 (2/9/10) |
Dismemberment Claims - AD&D only, not under Accident Insurance
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.
- Dismemberment Claim form
- Attending Physician's Statement of Dismemberment
- Authorization for Release of Health-Related Information
- Consumer Privacy Notice
| Dismemberment Claim | Form Number |
|---|---|
124001 (rev 07/09) | |
47987g (116486) |
| Attending Physician's Statement of Dismemberment | Form Number |
|---|---|
Attending Physician's Statement of Dismemberment (all states) | 47088f (116150) |
| Authorization for Release of Health-Related Information | Form Number |
|---|---|
127182 (rev 10/04) |
| Consumer Privacy Notice | Form Number |
|---|---|
47316c (116249) |
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 ING 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.
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