Accelerated Benefit Claims

Not all policies have this option -- check the policy or certificate. Remember to complete any applicable Administrator section(s) before distributing forms to insureds.

To submit a claim, you need to distribute the following forms to the insured:

  • Claim form
  • Attending Physician's Statement of Terminal Condition
  • Authorization for Release of Health-Related Information
  • Consumer Privacy Notice
  • Disclosure Statement (n/a for New York policies)
Claim form for Association Group Term Life and Individual YRTForm Number

Claim form for policies issued in New York

126267 (rev 11/10)

Claim form for policies issued in ALL OTHER STATES

44498f (115744)(rev 12/12)

Attending Physician's Statement of Terminal Condition
Form Number

Attending Physician's Statement of Terminal Condition

121489 (rev 12/12)

Authorization for Release of Health-Related Information
Form Number

Authorization for Release of Health-Related Information

127182 (rev 02/13)

Consumer Privacy Notice
Form Number

Consumer Privacy Notice

47316c (116249)

Disclosure Statement for claimant and any irrevocable beneficiaries
Form Number

Disclosure Statement for policies issued in Connecticut

44539CT

Disclosure Statement for group policies issued in Illinois

44539IL (rev 2/02)

Disclosure Statement for group policies issued in Indiana

44539IN-Assoc (6/05)

Disclosure Statement for policies issued in Kentucky

44539KY (3/09) + 159144

Disclosure Statement for individual policies issued in Maine

44539ME-AYRT (07/10) + page 2

Disclosure Statement for policies issued in Massachusetts

43734c

Disclosure Statement for policies issued in Montana

44539MT (rev 2/02)

Disclosure Statement for 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 individual policies issued in Washington

44539WA-AYRT (4/09) + page 2

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

44539 (rev 2/02)

Ad Log #8619