Death Claims
Waiver of Premium Claims
Accelerated Benefit Claims
Accident Claims
Total and Permanent Disability claims (NY Only)
Disability Income Claims
Critical Illness Claims
Administration Forms

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:
1) Claim form
2) Attending Physician's Statement of Terminal Condition
3) Authorization for Release of Health-Related Information
4) Consumer Privacy Notice
5) Disclosure Statement

Form Form Number
Claim form for group policies issued in New Jersey 121585 (rev 1/07)
Claim form for group policies issued in New York 121488 (rev 1/07)
Claim form for group policies issued in all other states 121583 (rev 6/07)

Attending Physician's Statement of Terminal Condition
Form Number
Attending Physician's Statement of Terminal Condition (all states) 121489 (rev 6/07)

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 47316b (116249)

Disclosure Statement -for claimant
and any irrevocable beneficiaries
Form Number
Disclosure Statement for group policies issued in Massachusetts 43734c (121970)
Disclosure Statement for group policies issued in Oregon 44539OR (8/05)
(137253)
Disclosure Statement for group policies issued in Washington 47404(WA24) (rev 1/04)
(121978)
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 Washington 44539WA (rev 5/06)
(121975)
Disclosure Statement for individual portable policies issued to individuals in Florida, Michigan, Minnesota, Montana, South Dakota, Utah or Vermont 44539 (rev 2/02)
(115753)