Waiver of Premium Claims

Not all policies have this option -- check the policy or certificate. There may also be eligibility limits for this benefit (i.e. the insured usually has to be under age 60 to apply). Remember to complete any applicable Administrator or Employer 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 Disability
  • Authorization for Release of Health-Related Information
  • Consumer Privacy Notice
Claim form for Association Group Term Life and Individual YRT Form Number

Claim form for policies issued in New York

126268 (rev 9/01/2014)

Claim form for policies issued in ALL OTHER STATES

44157i (115700) (rev 9/01/14)

Claim form for Individual TriTerm Form Number

Claim form

428571l (115591) (rev 9/01/14)

Attending Physician's Statement of Disability FOR ALL CLAIMS Form Number

Attending Physician's Statement of Disability

44540i (115754) (rev 9/01/14)

Authorization for Release of Health-Related Information FOR ALL CLAIMS Form Number

Authorization for Release of Health-Related Information

127182 (rev 9/01/14)

Consumer Privacy Notice FOR ALL CLAIMS 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.