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 NameForm Number

Claim form for group policies issued in New Jersey

121585 (rev 11/10)

Claim form for group policies issued in New York

121488 (rev 11/10)

Claim form for group policies issued in all other states

121583 (rev 12/12)

Attending Physician's Statement of Terminal Condition (all states)

121489 (rev 12/12)

Authorization for Release of Health-Related Information

127182 (rev 02/13)

Consumer Privacy Notice

47316c (116249)

Disclosure Statements
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 (3/09) +159144

Disclosure Statement for group policies issued in Massachusetts

43734c

Disclosure Statement for group policies issued in Montana

44539MT (rev 2/02)

Disclosure Statement for group policies issued in Oregon

44539OR (8/05)

+ 154673

Disclosure Statement for group policies issued in Washington

44539WA (rev 4/09)

+ page 2

Disclosure Statement for group policies issued in ALL OTHER STATES except New York

44539 (rev 2/02)

Disclosure Statement for individual portable policies issued to individuals in Montana

44539MT (rev 2/02)

Disclosure Statement for individual portable policies issued to individuals in Washington

44539WA (rev 4/09) + page 2

Disclosure Statement for individual portable policies issued to individuals in Florida, Michigan, Minnesota, South Dakota, Utah or Vermont

44539 (rev 2/02)

Ad Log #8619