Individual Claim Forms
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To properly submit your claim to us, please follow these three steps:
- 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.
- Second, please read our Notice of Information Privacy Practices form. You may wish to print a copy to retain in your records.
- 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.
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.
Waiver of Premium ext 508 or 429
Disability Income ext 353 or 567
|HIPAA-Compliant Authorization Forms||Description|
|- Authstd||Standard Form|
|- Authctnd||North Dakota|
|- Authpsychotherapy||Psychotherapy Notes|
|- Authpsychotherapy (CA)||Psychotherapy Notes (CA)|