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.

Group Claim Forms

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

Death Benefit

HIPAA Forms

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 Accident
  • Group Life, Accidental Death & Dismemberment
  • Group Short-Term Disability
  • Group Long-Term Disability
  • Group Voluntary Life, Accidental Death & Dismemberment

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.

  • Entrant not Requiring Evidence of Insurability

  • Entrant on Whom Evidence of Insurability is Required & Late Entrant

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.

  • Life
  • Disability Income (STD & LTD)

Short-Term Disability

Group Long-Term Disability

  • Entrant not Requiring Evidence of Insurability


  • Entrant on Whom Evidence of Insurability is Required & Late Entrant

Worksite Forms

New York State Disability Benefits Law