Accident and Accidental Dismemberment Claims

Not all policies have this option -- check the 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 Dismemberment
  • Authorization for Release of Health-Related Information
  • Consumer Privacy Notice
Claim form for Association Group Term Life and PAI Form Number

Claim form for group policies issued in New York

126270 (rev 9/01/14)

Claim form for group policies issued in ALL OTHER STATES

126269 (rev 9/01/14)

Attending Physician's Statement of Dismemberment Form Number

Attending Physician's Statement of Dismemberment

47088f (116150) (rev 9/01/14)

Authorization for Release of Health-Related Information Form Number

Authorization for Release of Health-Related Information

127182 (rev 9/01/14)

Consumer Privacy Notice Form Number

Consumer Privacy Notice

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

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.