Claim form instructions

Dental Claim Statement

This form is used for submitting dental claims.

Claim Statement for Life Insurance Coverage

This form is used for submitting life claims for employee, dependent or accidental death.

Accelerated Benefit Claim Statement - Insured/Spouse

This form is used for submitting accelerated benefit claims.

Accidental Dismemberment Claim Statement

This form is used for submitting accidental dismemberment claims.

ProviderFund

This brochure explains the ProviderFund program available to employees.

ProviderFund Supplemental Agreement

This form is to be completed if the Provider Fund option is chosen. Please attach to form KC2176.

Surviving Family Claim Statement

This form is used to determine spouse, children, and for parent of a deceased insured.

Disability Claim Statement-Life Insurance

This form is used for submitting life disability (waiver of premium) claims.

Addendum to Long-term Disability Claim Statement

This form is used for long-term disability claims.

Authorization for Release of Records

This form is used to obtain authorization for the release of all medical, psychiatric and psychological records.

Job Description and Requirements

This form is used for long-term disability claims.

Long-term Disability Claim Statement

This form is used for submitting long-term disability claims.

Long-term Disability Claim Statement (For use in New York)

This Union Security Life Insurance Company of New York form is used for submitting long-term disability claims.

Long-term Disability Claim Statement (Spanish / Español - Declaración Referente a la Reclamación por Concepto de Incapacidad a Largo Plazo)

This form is used for submitting long-term disability claims.

Long-term Disability Claim Statement - Conversion

This form is used for submitting long-term disability conversion claims.

Long-term Disability Claim Statement - Conversion (For use in New York)

This Union Security Life Insurance Company of New York form is used for submitting long-term disability conversion claims.

New York State Disability Claim Form

This form is used for submitting a claim for short term disability benefits under the New York state insurance fund.

Short-term Disability Claim Statement

This form is used for submitting short-term disability claims.

Short-term Disability Claim Statement (Spanish / Español - Declaración Referente a la Reclamación por Concepto de Incapacidad a Largo Plazo)

This form is used for submitting short-term disability claims.

Short-term Disability Claim Statement (For use in New York)

This Union Security Life Insurance Company of New York form is used for submitting short-term disability claims.

Supplementary Report for Benefits

This form is used for long-term disability claims.

Supplementary Report for Benefits (For use in New York)

This Union Security Life Insurance Company of New York form is used for long-term disability claims.

Job Search Log Sheet

This form is used by persons who have a disability related claim with our company. It is used to record, track and report information developed in the course of looking for employment.

Accident Claim Statement

This form is used for submitting an initial accident claim.

Employee Paid Supplemental Claim

This form is used when submitting additional documents after the initial claim statement has been sent.

Cancer Claim Statement

This form is used for submitting an initial cancer claim.

Employee Paid Supplemental Claim

This form is used when submitting additional documents after the initial claim statement has been sent.

Critical Illness Claim Statement

This form is used for submitting an initial critical illness claim.

Employee Paid Supplemental Claim

This form is used when submitting additional documents after the initial claim statement has been sent.

Hospital Confinement Indemnity “Gap” Claim Statement

This form is used for submitting an initial hospital confinement indemnity “Gap” claim.

Supplemental Hospital Confinement Indemnity "Gap" Claim Form

This form is used when submitting additional documents after the initial claim statement has been sent.