Group Benefits

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• Group Life Insurance
• Disability Income Insurance

Group Life and Disability Forms

Employee Enrollment & Evidence of Insurability Forms

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(all PDF format ) Employee Enrollment Forms Evidence of Insurability Forms

Disability Income Claim Forms

If a claim needs to be filed on behalf of your employee, select the applicable form below (all in PDF format ):

Group Disability Claim Application (LB-1065)
Reinsurer: Custom Disability Solutions

Group Disability Claim Application (LB-1065/DRMS)
Reinsurer: Disability RMS

Not sure which claim form to use?

Enter policy number below and click submit.

Policy Number

Disability Income Contact Information

Symetra Life Insurance Company
Group Division
777 108th Ave NE, Suite 1200
Bellevue, WA 98004-5135

Phone: (800) 426-7784
Hours: M – F, 7:00 am – 4:30 pm PT

Group Life Claim Forms

If your Group Life policy prefix begins with 01 or 16 (i.e. 01-000000) and a claim needs to be filed on behalf of your employee, select the applicable form below (all in PDF format ):

Accelerated Benefit Application (LB-1058/H)
Accelerated Benefit Application - Physician's Statement (LB-1057/H)
Application For Life Waiver Of Premium (LB-53/H)
Attending Physician's Statement (LB-83/H)
Authorization for Release of Medical Information - HIPAA (LB-85/H)
Claimant Statement (LB-2018/H)
Dependent's Death Claim Form (LB-36/H)
Employee Death or Dismemberment Claim Form (LB-34/H)

For all other Group Life policies:

Accelerated Benefit Application (LB-1058B)
Accelerated Benefit Application - Physician's Statement (LB-1057)
Application For Life Waiver Of Premium (LB-53)
Attending Physician's Statement (LB-83)
Authorization for Release of Medical Information - HIPAA (LB-85)
Claimant Statement (LB-2018)
Dependent's Death Claim Form (LB-36)
Employee Death or Dismemberment Claim Form (LB-34)

Group Life Contact Information

Hartford Claims Paying Office (for policy prefixes 01 and 16)	Bellevue Claims Paying Office (for all other policies)
Symetra Life Insurance Company Group Division PO Box 2993 Hartford, CT 06104-2993 Phone: (800) 943-2107 Hours: M – F, 8:00 am – 5:00 pm ET	Symetra Life Insurance Company Group Division PO Box 34690 Seattle, WA 98124-01690 Phone: (800) 426-7784 Hours: M – F, 7:00 am – 4:30 pm PT

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