Voluntary Disability Income Claims
(marketed as Horizon or Premier Disability Income)
To submit a claim, you need to distribute the following forms to the employee:
- Employee's Statement
- Attending Physician's Statement
- Authorization for Release of Health-Related Information
- Consumer Privacy Notice
You, the employer, need to complete and sign the Claim Notice Employer's Statement.
All completed forms need to be returned to the insurance company at the address shown at the top of each form.
| Employer Forms | Form Number |
|---|---|
Claim Notice Employer's Statement for certificates issued in all states other than New York | 49817d (160500)(rev 12/12) |
Claim Notice Employer's Statement for certificates issued in New York | 49817NYd |
| Employee Forms | Form Number |
|---|---|
160502 (rev 12/12) | |
Employee's Statement (with Authorization 127182 attached) for certificates issued in New York | 160503 (rev 9/11) |
Attending Physician's Statement for certificates issued in all states other than New York | 160504 (rev 12/12) |
Attending Physician's Statement for certificates issued in New York | 160505 (rev 8/11) |
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 U.S. 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.
