Disability
Click on subject matter to see listing of forms.
Short Term Disability
Long Term Disability
Return to Wellness
New York Disability Benefits Law (DBL)
State Variations

Short Term Disability
 
Employees should use this form to file a Short Term Disability claim.
The disabled employee’s doctor should fill out this form for the Short Term Disability claim.
Short Term Disability Supplemental Claim Report.
New York Employees Short Term Disability Claim Report.

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Long Term Disability
 
Application for LTD Benefits: The employee should use this form to file a claim for Long Term Disability benefits.
Attending Physician Statement – Long Term Disability.
Supplemental Statement of Disability -- Long Term Disability.
Authorization to Obtain and Re-Disclose Information.
Reimbursement Agreement.

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Return to Wellness
 
Return to Wellness: Checklist for employers and employees on how to use “Return to Wellness” wallet card to file a disability claim.

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New York Disability Benefits Law (DBL)

What you need to know about DBL

A Guide to your Insurance (DBL).
What You Need to Know about New York DBL.
Administrative Information about DBL.
Notice of Compliance Policy and Posters.
Employee/Employer Checklist for Return to Wellness ID Card

Premium & Invoice

How to Complete Your Premium Invoice – Per EE Rate that coincides with CY quarter
How to Complete Your Premium Invoice – Per EE Rate that does not coincide with CY quarter.
Per Employee Rate.
Per Employee Rate.

Preparing Monthly Statements

Instructions for preparing monthly statements.
Instructions for preparing monthly statements.

Preparing Quarterly Statements

Instructions for preparing quarterly statements.
Instructions for preparing quarterly statements.
Instructions for preparing quarterly statements.
Instructions for preparing quarterly statements. Instructions for preparing quarterly statements.
Instructions for New York Disability Benefits Quarter Report and Information.

Quarterly Report and Information

Quarterly Report and Information – DBL.
Quarterly Report and Information -- DBL.
Quarterly Report and Information – DBL.
Quarterly Report and Information – DBL.

Annual Report and Information

Annual Report and Information -- DBL

Claim Submission

DBL Information – Paper claims.
Submitting Claims – Disability Benefits.
New York Fraud Notice.

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State Variations

ME - Maine.

ME Third Party Notice. Employees can use this form if they wish a third party (relative) to be notified if coverage is terminated.
ME Notice of Admin Review. If reinstatement of coverage is denied due to organic brain disease, this notice says a third party (relative, attorney ) can be notified about the denial and right to appeal.

MN - Minnesota

MN Cancellation Notice requires employer to provide written notice to employees about cancellation of plan.

NJ - New Jersey

NJ What You Need to Know about NJ Total Disability Benefits .
NJ Notice and Proof of Claim for Disability Benefits: New Jersey residents should use this form to file a disability claim.

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