Total and Permanent Disability Claims (NY)

(New York ONLY)

There are time periods for applying for this benefit - check your policy and certificate. Remember to complete any applicable Employer's section(s) before distributing forms to employees.

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

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

Claim form for group policies issued in New York

123985 (rev 1/07)

Attending Physician's Statement of Disability

44540i (115754)

Authorization for Release of Health-Related Information

127182 (rev 02/13)

Consumer Privacy Notice

47316c (116249)

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