File a Claim
Group Disability Insurance Claims

If this is an Employer Sponsored Disability Product with your policy number beginning with AFL, please use the form below.

Short Term Disability/Long Term Disability Claim Form (DRMS)


For disability claims, we will need information from you, from your employer, and from your attending physician. Please provide all the information requested in Part A of the initial claim form. Your employer is responsible for providing the information in Part B, and your attending physician is responsible for providing the information in Part C.

In addition, please read and then sign the Authorization for Disclosure of Health Information (HIPAA form) included in Part A, as well as the separate Authorization for Disclosure of Health Information (HIPAA form).

Please date and sign all required forms where indicated.