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Forms
| Title | Purpose | Number |
|---|---|---|
| Accident Benefit Claim Form | Use this form to file an Accident insurance claim. | 17502 |
| Authorization for EFT of Payments (Annuities only) | Use to initiate electronic withdrawal of premiums or loan payments. | 1804-ANN |
| 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 |
| Qualified Joint and Survivor Annuity Notice and Spousal Consent | Use in any case of a qualified joint and survivor annuity. | 13018 |
| Request for 403(b) Tax-Sheltered Annuity Loan | Use to initiate TSA loan. | 7811 |
| Request for 72(t) or 72(q) Substantially Equal Periodic Payments | Use to initiate distribution as a SEPP. | 7180 |
| Request for Absolute Assignment and Successor Owner Endorsement | Use to transfer ownership of a contract. | 2527-ANN |
| Request for Account Reallocation | Use to reallocate funds between the Index Interest and Fixed Interest accounts in the Index Growth Annuity. | 13100 |
| Request for Change EFT of Annuity Payout | Use to change instruction for electronic "direct deposit" of payouts. | 11436 |
| Request for Change of Beneficiary | Use to change or add beneficiaries. | 6304 |
| Request for Change to Annuity Policy | Use to change address, name, payor or servicing agent on an in force contract. | 12428 |
| Request for Distribution from 457 Plan or Non-Qualified Deferred Compensation Plan | Use to initiate distribution from a 457 or non-qualified deferred compensation annuity. | 10853 |
| Request for Distribution from Individual Retirement Annuity 403(b) Tax-Sheltered Annuity or Pension | Use to initiate distribution from an IRA, TSA or pension-plan annuity. | 10050 |
| Request for Distribution from Non-Qualified Annuity | Use to initiate distribution from a non-qualified annuity. | 12411 |
| Request for EFT of Annuity Payout | Use to establish electronic "direct deposit" of payouts. | 11426 |
| Request for IRS Required Minimum Distribution | Use to initiate distribution as an IRS RMD. | 10516 |
| Request for Supplementary Contract Distribution | Use to initiate distribution as a settlement option. | 6592 |
| Request to Mail Payments to Financial Institution | Use to establish mailing of payouts to bank. | 10441 |
| 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 |
| Special Tax Notice for 457 Plan or Non-Qualified Deferred Compensation Plan | Use to provide information about tax consequences of a distribution from a 457 or non-qualified deferred compensation annuity. | 12300 |
| Special Tax Notice for Individual Retirement Annuity, 403(b) Tax-Sheltered Annuity or Pension Plan | Use to provide information about tax consequences of a distribution from an IRA, TSA or pension-plan annuity. | 12299 |
| Substitute IRS Forms W-4P and W-9 | Use in any case of a payout or taxable event to verify SSN or TIN. | 5031 |
| 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 |