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Group Claim Forms

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If you are an employer who has group coverage for life and/or disability, or a third party administrator who administers group benefits, please select from the following list of forms.

In addition to downloading your claim kit, you MUST also download the appropriate HIPAA-compliant Authorization form by selecting your appropriate state. If your state is not listed - Select standard HIPAA Authorization Form.

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

Claim Forms
- Life and AD&D	- TPA Life and AD&D
- Waiver	- TPA Waiver
- Dismemberment	- TPA Dismemberment
- Disability	- Creditor

HIPAA-Compliant Authorization Form	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)