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.

Form NameForm Number

Accident Insurance Claim (with Consumer Privacy Notice 47316c attached) for certificates issued by ReliaStar Life Insurance Company

139074 (rev 05/13)

Accident Insurance Claim (with Consumer Privacy Notice 47316c attached) for certificates issued by ReliaStar Life Insurance Company of New York

149256 (rev 05/13)

Wellness Benefit Rider Claims

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

Form NameForm Number

Accident Insurance Wellness Benefit Rider Claim (with Consumer Privacy Notice 47316c attached) for certificates issued by ReliaStar Life Insurance Company

150342 (rev 05/13)