Voluntary Disability Income Claims
(Other than Short Term Disability or Long Term Disability Claims)
You may be eligible to receive benefits under your Horizon or Premier Disability Income certificate of insurance. Please review your certificate for the eligibility requirements to receive benefits.
To submit a claim, please print the following forms below:
- Employee's Statement
- Attending Physician's Statement
- Authorization for Release of Health-Related Information
- Consumer Privacy Notice
Your employer will 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.
|Form Name||Form Number|
160502 (rev 12/12)
160503 (rev 9/11)
160504 (rev 12/12)
160505 (rev 811)
49817d (160500)(rev 12/12)
49817NYd 160501 (6/11)
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.Ad Log #8619