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Claim Forms

Dental, Vision, Life & Disability Forms

We want to make managing your benefits as easy as possible. Below are claim forms – with additional information – you can use to quickly and securely submit your benefit claims.

You or your dentist should send your claims to:

Renaissance
PO Box 17250
Indianapolis, IN 46217
Attn: Claims Department

NOTE: If the member number on your ID card is a six-digit number starting with one, please dial 800-894-4532 for eligibility and customer support.

For questions regarding your dental claim:

claims@renaissancefamily.com
888-358-9484

Your VSP Doctor will submit claims on your behalf. To submit an Out-Of-Network claim, you can contact VSP:

www.vsp.com

800-877-7195

The Renaissance Life and Disability claims team understands how important compassionate support and timely claims processing is to the peace of mind and financial wellbeing of employees and their families facing major life events such as disability or the death of a loved one.

This page contains forms and information about the claims process for our group life and disability products offered to employees through their employer sponsored benefit plans.

Contact Information
  • LIFE/DI CLAIMS CUSTOMER SERVICE: 844-368-6485
  • EMAIL: GroupClaims@RenaissanceFamily.com
  • FAX TO: 607-773-2276
  • MAIL: 2 Court St. Suite 102, Binghamton, NY 13901

Submit your disability claim as soon as it becomes clear that you will be off work longer than the elimination period specified in your policy. Please use the following forms to apply for group short or long term disability benefits.

Additional information:
Continuation of Life Coverage during Disability

If you stop work due to disability (including Workers’ Comp) and have exhausted or are not eligible for federal/state family medical leave, contact your employer immediately to discuss how this impacts any group term life coverage you may have been enrolled in. Please refer to your certificate of insurance for time limits to apply for continued life coverage during disability. If a continuation application is not submitted timely, coverage terminates as of the date of disability or the end of approved federal/state family medical leave, whichever is later. To apply for continuation of coverage during disability, submit the following form.

Life Waiver of Premium during Disability

In addition to the option to continue coverage during disability, your policy may also include a Waiver of Premium benefit. Waiver of Premium provisions typically require that:

  • Continuation of life coverage during disability must be approved by Renaissance and you must continue to remit premium payments to Renaissance until a Waiver of Premium claim determination is made
  • Total Disability (as defined in the policy) must begin before reaching the age limit specified in the policy
  • Total Disability (as defined in the policy) must continue for the minimum amount of time specified in the policy

To apply for Waiver of Premium, submit the following forms as soon as it is clear you will be continuously disabled longer than the period specified in the Waiver of Premium provision of your policy. Waiver of Premium claims should be submitted no later than 12 months after your date of disability.

Death

The following is a list of forms and documentation typically needed to file a death claim. Additional information may be requested by Renaissance as needed depending on the specifics of the claim.

  • Life and Accidental Death Claim Form Employee Statement [ADD-001C]: This form is required. For death of the employee, the form should be completed by the claimant/beneficiary. For death of a spouse/covered dependent, the form should be completed by the employee.
  • Employer’s Statement [ADD-005C]: This form is required and must be completed by the employer. The employer should attach copies of all beneficiary designation forms and changes, the most recent payroll record for one full pay period prior to the employee’s last day or date of death and a copy of the employee’s original enrollment form.
  • Death certificate: A final certified copy of the death certificate or other equivalent legal documentation is required and should be submitted with the claim form.
  • For Accidental Death please provide any of the listed documentation that is available:
    • Autopsy report
    • Police/accident report
    • Newspaper articles
  • Funeral Home Assignment form [FAL-001C]: This form is optional and should be completed if the beneficiary wishes to assign all or part of the benefit to cover funeral expenses. A copy of the itemized funeral bill should be submitted with this form.

Additional information:

Accidental Dismemberment

The following is a list of forms and documentation typically needed to file a claim for dismemberment benefits under a group life policy.

Accelerated Death

If your group life policy includes an Accelerated Death Benefit provision for advanced partial payment upon diagnosis of a terminal illness, submit the following claim forms. Please refer to the policy certificate for additional information and limitations applicable to the accelerated death benefit.

PLEASE NOTE: The following forms are subject to strict regulatory oversight and may be revised without notice. Please visit this site to retrieve current versions of claim forms for each claim submitted. Please do not save or print large quantities of forms downloaded from this site for future use. Outdated claim forms may be returned with instructions to complete the most current version approved by the state insurance department.

Disability Benefits (NY DBL)

To apply for New York State disability benefits, submit the below claim form no later than 30 days after the date you become disabled.

Paid Family Leave Benefits (NY PFL)

To apply for New York Paid Family leave, select the appropriate claim forms packet based on your reason for taking leave.

Additional Forms:

 

Additional Information:

PLEASE NOTE: The following forms are subject to strict regulatory oversight and may be revised without notice. Please visit this site to retrieve current versions of claim forms for each claim submitted. Please do not save or print large quantities of forms downloaded from this site for future use. Outdated claim forms may be returned with instructions to complete the most current version approved by the state insurance department.

Disability Benefits (NJ TDB)

To apply for New Jersey State disability benefits, submit the below claim form no later than 30 days after the date you become disabled.

Family Leave Benefits (NJ FLB)

To apply for New Jersey State family leave benefits, submit the below claim form no later than 30 days after your first date of leave.

Additional Forms:
Additional Information:

The following is a list of forms and documentation typically needed to file a claim for benefits under a group accident policy.

  • Group Accident Claim Form [GAC-101C]: This form is required and must be completed by the employee. If the employee is unable to complete the form, a representative may complete the form on their behalf.
  • Group Accident Attending Physician Statement for Claims [GAC-103C]: This form is required and must be completed by your treating healthcare provider.
  • Group Accident Employer Statement for Claims [GAC-102C]: This form is required and must be completed by your employer.
  • Spouse/Adult Dependent signature forms [GAC-104C]: This form is required if the claim is for Spouse, Domestic Partner, or Dependent Child 18 years of age or older.
  • Copy of birth or adoption papers: This is required if the claim is for a dependent child.
  • Itemized medical bills incurred as a result of the accident: Copies of itemized billing are required that indicate the diagnosis, individual services received (i.e. X-ray, MRI, dates of actual physical therapy, etc.), and actual charges. General balance due notices are not sufficient.
  • Police report: This is required if injury was a result of a motor vehicle accident and for any incidents investigated by any law enforcement agency.