Voluntary Disability Income Claims

(Other than Short Term Disability or Long Term Disability Claims)

You may be eligible to receive benefits under your Horizon or Premier Disability Income certificate of insurance. Please review your certificate for the eligibility requirements to receive benefits.

To submit a claim, please print the following forms below:

  1. Employee's Statement
  2. Attending Physician's Statement
  3. Authorization for Release of Health-Related Information
  4. Consumer Privacy Notice

Your employer will 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.

Form NameForm Number

Employee's Statement (with Authorization 127182 attached) for certificates issued in all states other than New York

160502 (rev 2/14)

Employee's Statement (with Authorization 127182 attached) for certificates issued in New York

160503 (rev 2/14)

Attending Physician's Statement for certificates issued in all states other than New York 

160504 (rev 2/14)

Attending Physician's Statement for certificates issued in New York 

160505 (rev 2/14)

Consumer Privacy Notice

47316c (116249)

Claim Notice Employer's Statement for certificates issued in all states other than New York

49817d (160500)(rev 2/14)

Claim Notice Employer's Statement for certificates issued in New York

49817NYd 160501 (2/14)

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