Cancer/Specified Disease Claims

(ReliaStar Life Insurance Company of New York ONLY)

You may be eligible to receive a Cancer/Specified Disease Benefit or a Cancer Screening Benefit under your Cancer policy (in New York, referred to as a Specified Disease policy). Please review your policy for the eligibility requirements to receive benefits.

To submit a claim for a Cancer/Specified Disease, please print the following forms below:

  • Cancer or Specified Disease Claim Form
  • Consumer Privacy Notice

You will need to return the completed claim form, an itemized bill from your medical provider, and supporting pathology/cytology/radiological reports to the address shown at the end of the claim form.

To submit a claim for a Cancer Screening Benefit, please print the following forms below:

  • Cancer Screening Claim Form
  • Consumer Privacy Notice

You will need to return the completed claim form, along with a copy of the itemized bill from your medical provider, to the insurance company at the address shown at the end of the claim form.

Form Name Form Number

Cancer or Specified Disease Claim

CAN-CLAIM-05 (135189) (rev 07/10)

Cancer Screening Claim

CAN-SCREEN-05 (135188) (rev 07/10)

Consumer Privacy Notice

47316c (116249)

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