Forms

Title Purpose Number
Accident Benefit Claim Form Use this form to file an Accident insurance claim. 17502
Balanced Care Vision Plan III Claim Use this form to initiate an eye care claim. SI 14068
Critical Illness Benefit Claim Form (Not in NY) Use this form to file a Critical Illness insurance claim. 17503
Dental Claim Use this form to report a treatment plan and to initiate a dental claim. SI 3943
Dental Claim (NY Only) Use this form to report a treatment plan and to initiate a dental claim. For use in New York only. SNY 3943
EFT setup for Disability Claim Payments Used to request the electronic funds transfer (EFT) disability claim payment option. SI 9571
EFT setup for Disability Claim Payments (NY Only) Used to request the electronic funds transfer (EFT) disability claim payment option. SNY 9571
Eye Med Vision Out of Network Claim Used to initiate an out of network eye care claim. SI 14070
Health Maintenance Screening Benefit Claim Form Use this form if you have the Health Maintenance Screening Benefit through your employer. 17430
Hospital Indemnity Benefit Claim Form (Not in NY) Use this form to file a Hospital Indemnity insurance claim. 17504
Long Term Disability Claim Packet (Not in NY) Use this packet to file a claim for a Long Term Disability plan issued outside of the state of New York. SI 3379
Long Term Disability Claim Packet (NY Only) Use this packet to file a claim for a Long Term Disability plan issued in the state of New York. SNY 3379
New Jersey State Disability Claim Packet Use this packet to file a claim through a New Jersey State Disability plan. SI 9426-RCO
New York State Disability Claim Packet Use this packet to file a claim through a New York State Disability plan. SNY 9457
Short Term Disability Claim Packet (Not in NY) Use this packet to file a claim for a Short Term Disability plan issued outside of the state of New York. SI 2047
Short Term Disability Claim Packet (NY Only) Use this packet to file a claim for a Short Term Disability plan issued in the state of New York. SNY 2047
Vision Claim Form Use this form to initiate a vision claim. SI 14068
Vision Claim Form (NY Only) Use this form to initiate a vision claim. For use in New York only. SNY 14069
Vision Claim Form (Spanish - NY Only) Use this form to initiate a vision claim (Spanish). For use in New York only. SNY 14069 SPU
Vision Claim Form (Spanish) Use this form to initiate a vision claim (Spanish). SI 14068 SPU
VSP Vision Out of Network Claim Used to request out of network eye care expense reimbursement. SI 14071
Waiver of Premium Claim Packet (Not in NY) If you have a life insurance policy issued outside of New York that includes the Waiver of Premium benefit, you can use this packet to request the waiver. SI 1284
Waiver of Premium Claim Packet (NY Only) If you have a life insurance policy issued in New York that includes the Waiver of Premium benefit, you can use this packet to request the waiver. SNY 1284