Accident Insurance Claims (Non-Compass)

You may be eligible to receive an Accident benefit and/or a Wellness benefit under your Accident Insurance certificate. Please review your certificate and riders for the eligibility requirements to receive benefits.

To submit an Accident Insurance Claim (Non-Compass):

Please print the Accident Insurance Claim form below. The Consumer Privacy Notice is attached.

Note: If you are submitting a disability claim under the Off Job Accident Disability Income Rider, your attending physician will also need to complete and sign the Physician's Disability Statement (section 4) on page 3. Your employer will need to complete and sign the Employer's Statement (section 5) on page 3.

Submit the completed and signed form to the address shown at the top of the form, along with any other required information such as itemized bill(s) or Explanation of Benefits (EOB).

Form NameForm Number

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

139074 (rev 2/7/14)

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

149256 (rev 2/7/14)

To submit a Wellness Benefit Rider Claim:

Please print the Wellness Benefit Rider Claim form below. The Consumer Privacy Notice is attached.

Submit the completed and signed form to the address shown at the top of the form.

Form NameForm Number

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

165760 (07/01/2014)