Forms

Title Purpose Numbersort descending
Health Maintenance Screening Benefit Claim Form Use this form if you have the Health Maintenance Screening Benefit through your employer. 17430
Accident Benefit Claim Form Use this form to file an Accident insurance claim. 17502
Critical Illness Benefit Claim Form (Not in NY) Use this form to file a Critical Illness insurance claim. 17503
Specified Disease Benefit Claim Form (Vermont Only) Use this form to file a Specified Disease insurance claim. 17503 VT
Hospital Indemnity Benefit Claim Form (Not in NY) Use this form to file a Hospital Indemnity insurance claim. 17504
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
Balanced Care Vision Plan III Claim Use this form to initiate an eye care claim. SI 14068
Vision Claim Form Use this form to initiate a vision claim. SI 14068
Vision Claim Form (Spanish) Use this form to initiate a vision claim (Spanish). SI 14068 SPU
Eye Med Vision Out of Network Claim Used to initiate an out of network eye care claim. SI 14070
VSP Vision Out of Network Claim Used to request out of network eye care expense reimbursement. SI 14071
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
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
Dental Claim Use this form to report a treatment plan and to initiate a dental claim. SI 3943
New Jersey State Disability Claim Packet Use this packet to file a claim through a New Jersey State Disability plan. SI 9426-RCO
EFT setup for Disability Claim Payments Used to request the electronic funds transfer (EFT) disability claim payment option. SI 9571
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
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
Health Maintenance Screening Benefit Claim Form (NY Only) Use this form if you have the Health Maintenance Screening Benefit through your employer. SNY 17430
Accident Benefit Claim Form (NY Only) Use this form to file an Accident insurance claim. SNY 17502
Specified Disease Benefit Claim Form (NY Only) Use this form to file a Specified Disease insurance claim. SNY 17503
PFL Bonding Leave Packet (NY Only) Use this packet for file a claim for bonding leave under Paid Family Leave in New York. SNY 19378
PFL Care of Family Member Packet (NY Only) Use this packet for file a claim for care of family member leave under Paid Family Leave in New York. SNY 19379
PFL Military Leave Packet (NY Only) Use this packet for file a claim for military exigency leave under Paid Family Leave in New York. SNY 19380
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
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
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
New York State Disability Claim Packet Use this packet to file a claim through a New York State Disability plan. SNY 9457
EFT setup for Disability Claim Payments (NY Only) Used to request the electronic funds transfer (EFT) disability claim payment option. SNY 9571