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Submit a disability claim online.

Please follow the steps below and provide as much information as possible. In Step 10, you’ll be able to review your answers before submitting your claim. A case manager may call you to confirm the information you’ve provided or to request additional details.

This service is offered by New York Life Group Benefit Solutions to employers and employees who wish to file a disability claim.

The information requested is required for us to begin reviewing your claim. It’s important that you provide us with complete and accurate information to avoid a delay in the processing of your claim.

You can submit your claim in one of two ways:

  1. Submit a disability claim below. Complete the secure online form, and we’ll call you if we need additional information.
  2. Submit a disability claim via fax or mail. Download, print, complete, sign, and mail or fax your claim form.

It may be necessary for us to obtain additional information or clarification from your employer and your health-care provider. If you have not done so, please complete a Disability Disclosure Authorization Form. This form grants us access to the information necessary to process your claim.

Have a question? Call us at 888-842-4462 between 7:00 a.m. and 7:00 p.m. Central Time

  1. Fraud Warning
  2. Sender
  3. Employee
  4. Employer
  5. Claim
  6. Illness
  7. Hospital
  8. Provider
  9. Employment
  10. Other Benefits
  11. Review

Fraud Warning
 

Any person who, knowingly and with intent to defraud any insurance company or other person: (1) Files an application for insurance or statement of claim containing any materially false information; or (2) conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act.

For residents of the District of Columbia and the following states, please see below: California, Colorado, Florida, Kentucky, Maryland, Minnesota, New Jersey, New York, Oregon, Pennsylvania, Rhode Island, Tennessee, Texas, and Virginia.

IMPORTANT CLAIM NOTICE

California Residents: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subjected to fines and confinement in state prison.

Colorado Residents: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.

District of Columbia Residents: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

Florida Residents: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

Kentucky Residents: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

Maryland Residents: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Minnesota Residents: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

New Jersey Residents: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

New York Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such violation.

Oregon Residents: Any person who knowingly and with intent to defraud any insurance company or other person: (1) files an application for insurance or statement of claim containing any materially false information; or (2) conceals, for the purpose of misleading, information concerning any material fact, may have committed a fraudulent insurance act.

Pennsylvania Residents: Any person who, knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Rhode Island Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit, or knowingly presents false information in an application for insurance, is guilty of a crime and may be subject to fines and confinement in prison.

Tennessee Residents: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

Texas Residents: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Virginia Residents: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated state law.

Have a question? Call 800-362-4462 between 7:00 a.m. and 7:00 p.m. Central Time

Sender Information

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Claimant (Employee) Information

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Employer Information

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Claim Information

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Illness Information

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Injury Information

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Maternity Information

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Hospital or Clinic Information

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If you're filing a maternity claim or did not visit a hospital or clinic, please skip this section and continue to the Provider Information section below.

Provider Information

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Please provide the following information about your provider

Employment Information

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Other Benefits and Offsets

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Please indicate the amount you're receiving (if applicable) from any of these sources.

Please review the information you've provided

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Before clicking the "Confirm" button below, print this page in landscape to keep for your records.

New York Life Group Benefit Solutions products and services are provided by Life Insurance Company of North America, New York Life Group Insurance Company of NY and New York Life Insurance and Annuity Corporation, subsidiaries of New York Life Insurance Company.

Life Insurance Company of North America is not licensed in New York and does not conduct insurance business in New York.