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

WAIVER OF PREMIUM CLAIMS

Not all group life policies have this option - check your certificate. There may be eligibility limits for this benefit (i.e. the employee usually has to be under age 60 to apply). Remember to complete any applicable Employer's section(s) before distributing forms to employees.

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

Form Form Number
Claim form for group policies issued in New York 45193g (115812 )
Claim form for group policies issued in all other states 42857j (115591)

Attending Physician's Statement of Disability
Form Number
Attending Physician's Statement of Disability 44540g (115754)

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)