Security Mutual Life - Benefits Division Insurance Forms

Insurance Forms

All forms are Acrobat Portable Document Files (PDF's). You will need Acrobat Reader Version 4.0 or higher in order to view them. To receive Acrobat Reader for free, click below.

Forms Directory

Group Claim Forms

Short-Term Disability
Long-Term Disability
Supplemental Claim Forms for Active Claims
Group Life Death Claims
HIPA Forms
-Virginia
-All Other States

Group Enrollment Forms

Worksite

Group Claim Forms

Short-Term Disability

New York Statutory Disability (DBL)

New Jersey Statutory Disability (TDB)

Short-Term Disability

Employers Group Benefits Trust (Small Group Products)

Long-Term Disability

GLTD Group Long Term Disability (Portland, ME Claim Office)

LTD Long Term Disability (Binghamton, NY Claim Office)

Employers Group Benefits Trust (Small Group Product)

Supplemental Claim Forms for Active Claims

New York Statutory Disability (DBL)

New Jersey Statutory Disability (DBL)

Short Term Disability

GLTD (Portland, ME Claim Office)

LTD (Binghamton, NY Claim Office)

Employers Group Benefits Trust (Small Group Product)

Death Benefit

Proof of Death - Claimant Statement

Explanation of Settlement Options

Employer's Statement

Request for Taxpayer Identification Number

Group Enrollment Forms

Life, Accidental Death & Dismemberment, Short-Term Disability

If you have any questions as to whether the "Standard Form" is applicable for your use, please contact either the Regional Director nearest you or the Secure Benefits Solutions Division of Security Mutual Life Insurance Company of New York at 1-800-927-8846.

Entrant not Requiring Evidence of Insurability

Entrant on Whom Evidence of Insurabiliy is Required & Late Entrant

Voluntary Products

Life

Disability Income (STD & LTD)

Secure Benefit Solutions

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