Short Term Disability Claims

(Weekly Income Benefits)

To submit a claim, provide the following forms to the employee:

  1. Short Term Disability Claim Notice Employer's Statement/Employee's Statement
  2. Authorization for Release of Health-Related Information
  3. Short Term Disability Attending Physician's Statement of Impairment and Function
  4. Consumer Privacy Notice

The employee must return the claim form to you (the employer) with the Employee's Statement and Authorization to Release Information sections completed. He/she also must return the completed Attending Physician's Statement to you, and the separate Authorization for Release of Health-Related Information.

Complete the Employer's Statement section of the claim form and send all the documents to the insurance company at the address shown at the top of the claim form.

Form NameForm Number

Claim Notice (with Authorization 127182 attached) for group policies issued in New York

145266 (rev 2/14)

Claim Notice (with Authorization 127182 attached) for group policies issued in all other states

40756j (115483)(rev 2/14)

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

145264 (rev 2/14)

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

41545h (115533)(rev 2/14)

Consumer Privacy Notice

47316c (116249)

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