Accident and Accidental Dismemberment Claims

Not all policies have this option -- check the certificate. Remember to complete any applicable Administrator section(s) before distributing forms to insureds.

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

  • Claim form
  • Attending Physician's Statement of Dismemberment
  • Authorization for Release of Health-Related Information
  • Consumer Privacy Notice
Claim form for Association Group Term Life and PAIForm Number

Claim form for group policies issued in New York

126270 (rev 7/09)

Claim form for group policies issued in ALL OTHER STATES

126269 (rev 12/12)

Attending Physician's Statement of DismembermentForm Number

Attending Physician's Statement of Dismemberment

47088f (116150)(rev 12/12)

Authorization for Release of Health-Related InformationForm Number

Authorization for Release of Health-Related Information

127182 (rev 02/13)

Consumer Privacy NoticeForm Number

Consumer Privacy Notice

47316c (116249)

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