Forms All forms are in Adobe® Acrobat® format. Click on the form you need and you should see the form appear in a new window. Print, complete and sign the form before submitting it to your employer or Boston Mutual Life Insurance Company.

INDIVIDUAL CLAIM FORMS:

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

• First, print and sign a HIPAA 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 recrods.
• 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 Authorization form.

• Accident
• Critical Illness
• Life and AD&D
  • 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