Benefits Division Forms
Note:
All forms are Adobe Acrobat Portable Document Files (PDF’s). Click on the Adobe icon to receive the latest Acrobat Reader for free.
Some products are not available in all states.
Group Claim Forms
Short-Term Disability
Long-Term Disability
Supplemental Claim Forms for Active Claims
Death Benefit
HIPAA Forms
New York State Paid Family Leave
Group Forms (other)
Beneficiary Form
Conversion Forms
NY DBL Certificate of Insurance Coverage DB120.1
NY DBL (Statement of Rights)
Refusal of Group Insurance
Group Employer Applications
Group Enrollment Forms
Group Accident
Life, Accidental Death & Dismemberment
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.
Voluntary Products
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.