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