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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
Short-Term Disability Claim Statement - Employer
Short-Term Disability Claim Statement - Employee
Short-Term Disability Claim Statement - APS
SLHIC Disability Claim Stmt - Behavioral Treating Provider
SLHIC HIPAA
Short Term Disability Supplemental Claim Report.
New York Employees Short Term Disability Claim Report.
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Long Term Disability
Long-Term Disability Claim Statement - Employer
Long-Term Disability Claim Statement - Employee
Long-Term Disability Claim Statement - APS
SLHIC Disability Claim Stmt - Behavioral Treating Provider
SLHIC HIPAA
SLHIC Reimbursement
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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 - Coinciding with CY Quarter.
Per Employee Rate - Does Not Coincide with CY Quarter.
Preparing Monthly Statements
Instructions for preparing monthly statements-rates per $10 of benefits.
Instructions for preparing monthly statements- per employee rates.
Preparing Quarterly Statements
Instructions for preparing quarterly statements-rates per $10 of benefits.
Instructions for preparing quarterly statements- per employee rates.
Instructions for New York Disability Benefits Quarter Report and Information.
Quarterly Report and Information
Quarterly Report and Information – DBL.
Instructions for preparing quarterly statements - Partners and Proprietors.
Instructions for preparing quarterly statements - Hourly/Salaried.
Instructions for preparing quarterly statements - Covered Payroll.
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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