Search

Employers: submit a claim for your employee and/or their dependents in one of two ways

Choose one of the options below:

  1. I am filing a Group Life or Accidental Death Claim 
  2. I am filing a Group Life Accidental Dismemberment or Premium Waiver claim

If you do not wish to complete this form electronically, you can submit our claim form via fax or mail. 

Have a question on an existing Group life, accidental death and dismemberment or waiver claim? Call us at 800-238-2125 between 8:00 a.m. and 5:00 p.m. ET.

If you call outside this time frame, please leave a voicemail message, and a representative will respond the next business day.

Please provide as much information as possible in the steps below.  The information requested in these steps are required for us to begin reviewing the claim. It’s important that you, as the employer, provide us with complete and accurate information to avoid delays in processing the claim.

In Step 15, you’ll be able to review your answers prior to submitting your claim. A case manager may call you to confirm the information you’ve provided or to request additional details.

Form

  1. Fraud Warning
  2. Sender
  3. Employee
  4. Employer
  5. Policy
  6. Employment 1
  7. Employment 2
  8. Coverage
  9. Claim
  10. Benefit
  11. Status
  12. Details
  13. Medical
  14. 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 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 4, 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

1 of 13

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

Employee/Member Information

2 of 13

Employer/Association Information

3 of 13

Policy Details

4 of 13

Employment Information

5 of 13

Employment Status

6 of 13

Coverage Details

7 of 13

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

Claim Information

8 of 13

Benefit Selection

9 of 13

Benefit Selection

9 of 13

Death Claim Details

10 of 13

Accelerated Death Details

10 of 13

Waiver or Total and Permanent Disability

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:

Fax: 877-300-6770

New York Life Group Benefit Solutions
PO Box 22328
Pittsburgh, PA 15222-0328

Accidental Death Claim Information

10 of 13

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

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.

New York Life Group Benefit Solutions
PO Box 22328
Pittsburgh, PA 15222-0328

Fax: 877-300-6770

 

Accidental Dismemberment Claim Information

10 of 13

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

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

New York Life Group Benefit Solutions
PO Box 22328
Pittsburgh, PA 15222-0328

Fax: 877-300-6770

Short Term Permanent and Total Disability Information

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

11 of 13

Employee/Member's Spouse or Domestic Partner Information

11 of 13

Employee/Member's Dependent Child Information

11 of 13

Employee/Member Information

11 of 13

Employee/Member's Spouse or Domestic Partner Information

11 of 13

Employee/Member Information

11 of 13

Employee/Member's Spouse or Domestic Partner Information

11 of 13

Employee/Member's Dependent Child Information

11 of 13

Employee/Member Information

11 of 13

Employee/Member's Spouse or Domestic Partner Information

11 of 13

Employee/Member's Dependent Child Information

11 of 13

Medical History

12 of 13

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

Medical History

12 of 13

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

Medical History

12 of 13

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

Medical History

12 of 13

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

Medical History

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

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

Guidance and support for life’s most challenging moments

Coping with grief is not easy, but we're here to support you along the way. New York Life Group Benefit Solutions provides resources to help families through life's unexpected challenges.

See beneficiary resources

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.