Accidental Death and Dismemberment (AD&D) Insurance Claims

Please distribute the following forms to the employee/insured. Be sure to complete and sign the Employer's sections of the claim form before distributing.

  1. Accidental Dismemberment Claim form
  2. Attending Physician's Statement of Dismemberment
  3. Authorization for Release of Health-Related Information
  4. Consumer Privacy Notice
Form NameForm Number

Accidental Dismemberment Claim for group policies issued in New York

124001 (rev 07/09)

Accidental Dismemberment Claim for group policies issued in all other states

47987g (116486)(rev 12/12)

Attending Physician's Statement of Dismemberment (all states)

47088f (116150)(rev 12/12)

Authorization for Release of Health-Related Information all states

127182 (rev 02/13)

Consumer Privacy Notice

47316c (116249)