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

SHORT TERM DISABILITY CLAIMS
(WEEKLY INCOME BENEFITS)

To submit a claim, provide the following forms to the employee:
1) Short Term Disability Claim Notice Employer's Statement/Employee's Statement,
2) Short Term Disability Attending Physician's Statement of Impairment and Function,
3) Authorization for Release of Health-Related Information, and
4) Consumer Privacy Notice

The employee must return the claim form to you (the employer) with the Employee's Statement and Authorization to Release Information sections completed. He/she also must return the completed Attending Physician's Statement to you, and the separate Authorization for Release of Health-Related Information.

Complete the Employer's Statement section of the claim form and send all the documents to the insurance company at the address shown at the top of the claim form.

Short Term Disability Claim Notice Employer's Statement/Employee's Statement

Form Number
Claim Notice for group policies issued in New York 145266 (rev 8/07)
Claim Notice for group policies issued in all other states 40756f (115483)

Short Term Disability Attending Physician's Statement of Impairment and Function

Form Number
Attending Physician's Statement for group policies issued in New York 145264 (rev 8/07)
Attending Physician's Statement for group policies issued in all other states 41545e (115533)

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