Individual Claims 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.
For all individual life death claims, we must have an original or certified death certificate.
Please click each topic to collapse/expand each section to see the forms available.
Individual Life Death Claim Forms
- Affidavit for Children
- Authorization for Disclosure of Health and Other Information (HIPAA) – Claimant
- Authorization for Disclosure of Health and Other Information (HIPAA) – Claimant – Virginia Only
- Authorization for Disclosure of Health and Other Information (HIPAA) – Decedent
- Authorization for Disclosure of Health and Other Information (HIPAA) – Decedent – Virginia Only
- Collateral Assignee’s Agreement
- Lost Policy Certificate
- Request for Taxpayer Identification Number
Waiver of Premium for Disability Claim Forms
Individual Accident Policy Claim Form
- The Individual Claim Department may be contacted directly at:
- Security Mutual Life Insurance Company of New York
- Attn: Individual Claims
- P.O. Box 1625
- 100 Court Street
- Binghamton, NY 13902-1625
- For Individual Death Claims
- Telephone: 1-800-846-6305
- E-mail: individuallifeclaims@smlny.com
- Fax: 1-607-773-2276
- For Individual Accident Claims
- Telephone: 1-800-927-8846 Option 2
- E-mail: individuallifeclaims@smlny.com
- Fax: 1-607-773-2276