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

VOLUNTARY DISABILITY INCOME CLAIMS

To submit a claim, you need to distribute the following forms to the employee:
1) Employee's Claim Notice
2) Attending Physician's Statement
3) Authorization for Release of Health-Related Information
4) Consumer Privacy Notice

You, the employer, need to complete and sign the Claim Notice Employer’s Statement.

All completed forms need to be returned to the insurance company at the address shown at the top of each form.

Claim Notice Employer's Statement Form Number
Claim Notice Employer's Statement for certificates issued in all states other than New York 49817c (136499)
Claim Notice Employer's Statement for certificates issued in New York 49817NYd (136500)

Employee's Claim Notice Form Number
Employee's Claim Notice for certificates issued in all states other than New York 136501 (rev 6/07)
Employee's Claim Notice for certificates issued in New York 136502 (rev 8/07)

Attending Physician's Statement Form Number
Attending Physician's Statement for certificates issued in all states other than New York 136503 (rev 3/07)
Attending Physician's Statement for certificates issued in New York 136504 (rev 8/07)

Authorization for Release of Health-Related Information
Form Number
Authorization 127182 (rev 10/04)

Consumer Privacy Notice Form Number
Consumer Privacy Notice 47316b (116249)


To download all required forms into one PDF, choose one of these based on the state where the group policy was issued:
non-New York New York