Forms > Claims Forms

Individual Claim Forms

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To properly submit your claim to us, please follow these three steps:

1. First, print and sign a HIPAA-Compliant Authorization form. Please select the form for the state in which you reside. If your state is not listed, please choose the standard form. This form is required to be returned with the claim form.
2. Second, please read our Notice of Information Privacy Practices form. You may wish to print a copy to retain in your records.
3. Third, once the above two steps are completed, please print and complete your Claim Form.

Please select your appropriate claim form from those listed below. Your Claim form must be returned with the signed HIPAA-Compliant Authorization form.

You also need to review and print our Notice of Information Privacy Practices for your records.

Accident Claim Forms
Accident Claim Form

Critical Illness Forms
Please Download the correct form based on the Critical Illness you are claiming	If you are claiming a Health or Genetic Screening Test Only, Please download this form:
Cancer/Carcinoma In Situ	Health/Genetic Screening Test Only
Myocardial Infarction (Heart Attack)
Coronary Artery Bypass Surgery
Major Organ Transplant
Stroke
Renal Failure (Kidney Failure)

Life and Accidental Death Benefit Forms
Life and Accidental Death Benefit Form You are the beneficiary of an Individual Life Insurance Policy and have suffered a loss You are the owner of an Individual Life Insurance Policy and have suffered a loss

Disability Income / Waiver:
To determine correct disability form, please enter your policy number:

If you are unsure of the specific Disability Income / Waiver form you need and do not have your policy number available, please contact the toll free number listed below for personal assistance. Please select the appropriate extension depending on the type of claim you wish to file.

1-800-669-2668
Waiver of Premium ext 508 or 429
Disability Income ext 353 or 567

HIPAA-Compliant Authorization Forms	Description
- Authstd	Standard Form
- Authca	California
- Authctnd	Connecticut
- Authme	Maine
- Authmn	Minnesota
- Authctnd	North Dakota
- Authok	Oklahoma
- Authvt	Vermont
- Authwi	Wisconsin
- Authpsychotherapy	Psychotherapy Notes
- Authpsychotherapy (CA)	Psychotherapy Notes (CA)