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 following states, please see below: California, Colorado, District of Columbia, Florida, Kentucky, Maryland, Minnesota, New Jersey, New York, Oregon, Pennsylvania, Rhode Island, Tennessee, Texas or 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 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: 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 $5000 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 application or files a claim containing a false or deceptive statement may have violated state law.

Have a question about your claim form or wish to file your claim telephonically? Call 1.800.362.4462 and select option 1, between 7 am and 7 pm Central Time. If you call outside this time, please leave a voicemail message and a representative will respond the next business day.

Sender Information

Step 1 of 13

If you are the insured or beneficiary, please contact your employer benefits department.

Employee/Member Information

Step 2 of 13

Employer/Association Information

Step 3 of 13

Policy Details

Step 4 of 13

Employment Information

Step 5 of 13

Employment Status

Step 6 of 13

Coverage Details

Step 7 of 13

If claim is for dependent benefits, please complete the following as well:

Claim Information

Step 8 of 13

Benefit Selection

Step 9 of 13

Benefit Selection

Step 9 of 13

Death Claim Details

Step 10 of 13

Accelerated Death Details

Step 10 of 13

Waiver or Total And Permanent Disability

Step 10 of 13

If the employee is recieving Social Security benefits, please provide us with a copy of the most recent decision(Award or Denial).Please fax the information to:

New York Life Group Benefit Solutions

PO Box 22328

Pittsburgh, PA 15222-0328

Fax: 877-300-6770

Accidental Death Claim Information

Step 10 of 13

Please mail or fax the following information to the claim office:

New York Life Group Benefit Solutions

PO Box 22328

Pittsburgh, PA 15222-0328

Fax: 877-300-6770

A copy of the police report or news articles if available to you.

Copies of any autopsy, toxicology or coroner’s report if available to you.

Accidental Dismemberment Claim Information

Step 10 of 13

Please mail or fax the following information to the claim office:

New York Life Group Benefit Solutions

PO Box 22328

Pittsburgh, PA 15222-0328

Fax: 877-300-6770

Please provide a copy of the police report or news articles if available to you.

Short Term Permanent And Total Disability Information

Step 10 of 13

If the employee is receiving Social Security benefits, please provide us with a copy of the most recent decision (Award or Denial). Please fax the information to:

New York Life Group Benefit Solutions

PO Box 22328

Pittsburgh, PA 15222-0328

Fax: 877-300-6770

Employee/Member Information

Step 11 of 13

Employee/Member's Spouse or Domestic Partner Information

Step 11 of 13

Employee/Member's Dependent Child Information

Step 11 of 13

Employee/Member Information

Step 11 of 13

Employee/Member's Spouse or Domestic Partner Information

Step 11 of 13

Employee/Member Information

Step 11 of 13

Employee/Member's Spouse or Domestic Partner Information

Step 11 of 13

Employee/Member's Dependent Child Information

Step 11 of 13

Employee/Member Information

Step 11 of 13

Employee/Member's Spouse or Domestic Partner Information

Step 11 of 13

Employee/Member's Dependent Child Information

Step 11 of 13

Medical History

Step 12 of 13

Please provide information about the hospitals, clinics or physicians that treated the Deceased during the past five years.

Medical History

Step 12 of 13

Please provide information about the hospitals, clinics or physicians that treated the Deceased during the past five years.

Medical History

Step 12 of 13

Please provide information about the hospitals, clinics or physicians that treated the Deceased during the past five years.

Medical History

Step 12 of 13

Please provide information about the hospitals, clinics or physicians that treated the Deceased during the past five years.

Medical History

Step 12 of 13

Please provide information about the hospitals, clinics or physicians that treated the Deceased during the past five years.

Please review the information you've provided

Step 13 of 13

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

Please remember to send enrollment and beneficiary information, if applicable. If you have additional information to provide, please forward the information to:

New York Life Group Benefit Solutions

PO Box 22328

Pittsburgh, PA 15222-0328

Fax: 877-300-6770

Scanned documents: Claims.Pghlif2@newyorklife.com 

Telephone Number: 800-238-2125