Long Term Disability Claims

(Monthly Income Benefits)

Remember to complete any applicable Employer form(s) or section(s) before distributing forms to employees.

To submit a claim, you (the employer) need to complete the following forms:

  1. Long Term Disability Claim Notice Employer's Statement, and
  2. Long Term Disability Occupational Demands

The completed Occupational Demands form (with a copy of the employee's job description attached) needs to be provided to the employee along with the following forms:

  1. Disability Claim Filing Instructions
  2. Long Term Disability Employee's Statement
  3. Attending Physician's Statement of Impairment and Function
  4. Authorization for Release of Health-Related Information, and
  5. Consumer Privacy Notice
Employer Forms
Form Number

Employer's Statement for group policies issued in New York

49256e (117478)

Employer's Statement for group policies issued in all other states

35365g (115164)(rev 12/12)

Employer's Statement for group policies issued outside of New York when ALSO filing a claim for Waiver of Premium under the plan's Life Insurance policy

48452g (116840)(rev 12/12)

Employer's Statement for group policies issued in New York when ALSO filing a claim for Waiver of Premium under the plan's Life Insurance policy

126313 (rev 01/11/2010)

Occupational Demands form for group policies issued in New York

49257e (117479)

Occupational Demands form for group policies issued in all other states

35368f (115166)

Employee Forms
Form Number

Disability Claim Filing Instructions

154969 (01/14/2010)

Employee's Statement for group policies issued in New York

49262g (117484)

Employee's Statement for group policies issued in all other states

35366m (115165)(rev 12/12)

Attending Physician's Statement for group policies issued in New York

49259d (117481)

Attending Physician's Statement for group policies issued in all other states

48664i (117010)(rev 12/12)

Authorization for Release of Health-Related Information

127182 (rev 02/13)

Consumer Privacy Notice 

47316c (116249)

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