Voluntary Disability Income Claims

(marketed as Horizon or Premier Disability Income)

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

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

You, the employer, 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.

Employer Forms
Form Number

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

49817d (160500)(rev 12/12)

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

49817NYd
160501 (6/11)

Employee FormsForm Number

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

160502 (rev 12/12)

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

160503 (rev 9/11)

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

160504 (rev 12/12)

Attending Physician's Statement for certificates issued in New York

160505 (rev 8/11)

Consumer Privacy Notice

47316c  116249