Total and Permanent Disability Claims (NY)
For Group Term Life (New York ONLY)
Note: This benefit is not currently available.
To submit a claim, you need to distribute the following forms to the insured:
- Claim form
- Attending Physician's Statement of Disability
- Authorization for Release of Health-Related Information
- Consumer Privacy Notice
| Claim form for Association Group Term Life (NY Only) | Form Number |
|---|---|
Claim Form | TBD |
| Attending Physician's Statement of Disability | Form Number |
|---|---|
44540i (115754) |
| Authorization for Release of Health-Related Information | Form Number |
|---|---|
127182 (rev 10/04) |
| Consumer Privacy Notice | Form Number |
|---|---|
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 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
