Group Benefits

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• Disability Income Insurance

Group Life Insurance

Employee Enrollment & Evidence of Insurability Forms

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

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)

Contact Information

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