ING Financial Services | Accelerated Benefit

Accelerated Benefit Claims

Not all group life policies have this option - check your certificate. Remember to complete any applicable Employer's section(s) before distributing forms to employees/insureds.

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

Claim form
IRS Form W-9
Attending Physician's Statement of Terminal Condition
Authorization for Release of Health-Related Information
Consumer Privacy Notice
Disclosure Statement

Form	Form Number
Claim form for group policies issued in New Jersey	121585 (rev 1/09)
Claim form for group policies issued in New York	121488 (rev 1/09)
Claim form for group policies issued in all other states	121583 (rev 1/09)
IRS Form W-9 English version	Form W-9 (10/07)
IRS Form W-9 Spanish version	Form W-9 (SP) (7/08)

Attending Physician's Statement of Terminal Condition	Form Number
Attending Physician's Statement of Terminal Condition (all states)	121489 (rev 1/09)

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 group policies issued in Connecticut	44539CT
Disclosure Statement for group policies issued in Illinois	44539IL (rev 2/02)
Disclosure Statement for group policies issued in Kentucky	44539KY
Disclosure Statement for group policies issued in Massachusetts	43734c (121970)
Disclosure Statement for group policies issued in Montana	44539MT (rev 2/02) (121971)
Disclosure Statement for group policies issued in Oregon	44539OR (8/05) (137253)
Disclosure Statement for group policies issued in Washington	44539WA (rev 4/09) (121975)
Disclosure Statement for group policies issued in ALL OTHER STATES except New York	44539 (rev 2/02) (115753)
Disclosure Statement for individual portable policies issued to individuals in Montana	44539MT (rev 2/02) (121971)
Disclosure Statement for individual portable policies issued to individuals in Washington	44539WA (rev 4/09)
Disclosure Statement for individual portable policies issued to individuals in Florida, Michigan, Minnesota, South Dakota, Utah or Vermont	44539 (rev 2/02) (115753)

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.

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