Total and Permanent Disability Claims (NY)

For Group Term Life (New York ONLY)

Note: This benefit is not currently available.

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

  • Claim form
  • Attending Physician's Statement of Disability
  • Authorization for Release of Health-Related Information
  • Consumer Privacy Notice
Claim form for Association Group Term Life (NY Only)Form Number

Claim Form

TBD

Attending Physician's Statement of DisabilityForm Number

Attending Physician's Statement of Disability

44540i (115754)

Authorization for Release of Health-Related InformationForm Number

Authorization for Release of Health-Related Information

127182 (rev 02/13)

Consumer Privacy NoticeForm Number

Consumer Privacy Notice

47316c (116249)

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