Living Benefit Claim

For Waiver of Premium, Disability, Accelerated Death Benefits, Unemployment Rider Benefits

To notify us of a claim, please fill out the form below and we will provide the appropriate information to complete the claim process.

To notify us by phone call toll free: 1-800-732-8939

Once your notice of claim has been received, you can expect our reply to be sent within 5 business days. Please be sure to indicate if you wish to receive your reply by mail or by e-mail.

* Required fields

Insured’s Name:

Policy Number:

Date of Birth:

Onset Date of Condition/Illness/Event:

Details of the Condition/Illness/Event:

Rider Type

Your Name:

Your Mailing Address Line 1:

Your Mailing Address Line 2:

City:

State:

ZIP Code:

Your Daytime Phone Number:

Your Email Address:

Contact Preference:

E-Mail

Mail

Your Relationship to Insured (if other than Insured):

Comments:

* Required Entries

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