Statement of Intent

(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.

Form NameForm Number

Statement of Intent form for group life policies issued by ReliaStar Life Insurance Company

114963 (24661h)

Statement of Intent form for group life policies issued by ReliaStar Life Insurance Company of New York

116013 (46559d)

Ad Log #8619