Accelerated Benefit Claims

Employee Benefits

Not all policies have this option -- check the policy or certificate. Remember to complete any applicable Administrator section(s) before distributing forms to insureds.

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

Claim form
Attending Physician's Statement of Terminal Condition
Authorization for Release of Health-Related Information
Consumer Privacy Notice
Disclosure Statement (n/a for New York policies)

Claim form for Association Group Term Life and Individual YRT	Form Number
Claim form for policies issued in New York	126267 (rev 11/10)
Claim form for policies issued in ALL OTHER STATES	44498f (115744)

Attending Physician's Statement of Terminal Condition	Form Number
Attending Physician's Statement of Terminal Condition	121489 (rev 5/10)

Authorization for Release of Health-Related Information	Form Number
Authorization for Release of Health-Related Information	127182 (rev 10/04)

Consumer Privacy Notice	Form Number
Consumer Privacy Notice	47316c (116249)

Disclosure Statement for claimant and any irrevocable beneficiaries	Form Number
Disclosure Statement for policies issued in Connecticut	44539CT
Disclosure Statement for group policies issued in Illinois	44539IL (rev 2/02)
Disclosure Statement for group policies issued in Indiana	44539IN-Assoc (6/05)
Disclosure Statement for policies issued in Kentucky	44539KY (3/09) + 159144
Disclosure Statement for individual policies issued in Maine	44539ME-AYRT (07/10) + page 2
Disclosure Statement for policies issued in Massachusetts	43734c
Disclosure Statement for policies issued in Montana	44539MT (rev 2/02)
Disclosure Statement for policies issued in Oregon	44539OR (8/05) + 154673
Disclosure Statement for group policies issued in Washington	44539WA (rev 4/09) + page 2
Disclosure Statement for individual policies issued in Washington	44539WA-AYRT (4/09) + page 2
Disclosure Statement for policies issued in ALL OTHER STATES except New York	44539 (rev 2/02)

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

Accelerated Benefit Claims

Access Your Account:

Forms Library

Employee Benefits Logins