Authorization for Electronic Funds Transfer

(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.

Form NameForm Number

Authorization for Electronic Funds Transfer for group policies issued by ReliaStar Life Insurance Company

47996d (116488)

Authorization for Electronic Funds Transfer for group policies issued by ReliaStar Life Insurance Company of New York

49258b (117480)

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