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Benefits Division Forms

Note: All forms are Adobe Acrobat Portable Document Files (PDFs). 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

New York Statutory Disability (DBL)

New Jersey Statutory Disability (TDB)

New Jersey Statutory Disability (FLB)

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


HIPAA Forms

Virginia

All Other States


New York State Paid Family Leave

 

Group Forms (Other)
Beneficiary Form

Beneficiary Form

Beneficiary Form Spanish


Conversion Forms

New York

Rhode Island

All Other States


NY DBL (Statement of Rights)

NY DBL (Statement of Rights)


Refusal of Group Insurance

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 Form
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

New York State Disability Benefits Law

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