Accelerated Benefit Claims

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 9/01/2014)

Claim form for policies issued in ALL OTHER STATES

44498f (115744)(rev 9/01/14)

Attending Physician's Statement of Terminal Condition Form Number

Attending Physician's Statement of Terminal Condition

121489 (rev 9/01/14)

Authorization for Release of Health-Related Information Form Number

Authorization for Release of Health-Related Information

127182 (rev 09/01/14)

Consumer Privacy Notice Form Number

Consumer Privacy Notice

47316c (116249) (rev 5/01/14)

Disclosure Statement for claimant and any irrevocable beneficiaries Form Number

Disclosure Statement for policies issued in Connecticut

44539CT (rev 9/01/14)

Disclosure Statement for group policies issued in Illinois

44539IL (rev 9/01/14)

Disclosure Statement for group policies issued in Indiana

44539IN-Assoc (rev 9/01/14)

Disclosure Statement for policies issued in Kentucky

44539KY (rev 9/01/14) + 159144

Disclosure Statement for individual policies issued in Maine

44539ME-AYRT (rev 9/01/14) + page 2

Disclosure Statement for policies issued in Massachusetts

43734c (rev 9/01/14)

Disclosure Statement for policies issued in Montana

44539MT (rev 9/01/14

Disclosure Statement for policies issued in Oregon

44539OR (rev 9/01/14) + 154673

Disclosure Statement for group policies issued in Washington

44539WA (rev 9/01/14) + page 2

Disclosure Statement for individual policies issued in Washington

44539WA-AYRT (rev 9/01/14) + page 2

Disclosure Statement for policies issued in ALL OTHER STATES except New York

44539 (rev 9/01/14)

Voya™ 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 Voya™ 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.