Critical Illness and Wellness Benefit Claims

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

  1. Claim form
  2. Attending Physician's Statement of Critical Illness (not used for Wellness claims)
  3. Authorization to Release Information (not used for Wellness claims)
  4. Consumer Privacy Notice
Form NameForm Number

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

161609 (10/2011) 

Critical Illness Claim

126173 (rev 11/10)

Critical Illness Only - Wellness Benefit Claim

126172 (rev 07/10)

Attending Physician's Statement of Critical Illness

126171 (rev 07/10)

Authorization to Release Information

132542 (rev 9/30/09)

Consumer Privacy Notice

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.

Ad Log #8619

Forms Library

Employee Benefits Logins