Waiver of Premium Claims

Not all group life policies have this option - check your certificate. There may be eligibility limits for this benefit (i.e. the employee usually has to be under age 60 to apply). 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

45193h (115812)

Claim form for group policies issued in all other states

428571l (115591)(rev 12/12)

Attending Physician's Statement of Disability

44540i (115754)(rev 12/12)

Authorization for Release of Health-Related Information

127182 (rev 02/13)

Consumer Privacy Notice

47316c (116249)

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