Are you a plan administrator?
Use these forms to support a plan member’s life insurance claim relating to accidental death or dismemberment (AD&D) and specific loss. You'll find instructions on how to return the completed form on the form itself.
Download a form
Download the form and print it, or fill it out in Adobe Reader XI or higherOpens a new website in a new window - Opens in a new window (not your browser) and save.
Use this form to provide information from your doctor about your accidental dismemberment or specific loss claim.
Use this form to apply for supplementary benefits with an accidental dismemberment or specific loss claim.