Dental Claims
You or your dentist should send your claims to:
Renaissance
PO Box 17250
Indianapolis, IN 46217
Attn: Claims Department
NOTE: Members who are part of an employer-sponsored group plan, please call 800-894-4532.
For questions regarding your claim:
Phone: 888-358-9484
Email: claims@renaissancefamily.com
For Solstice DHMO dental claims:
If the dental office is submitting electronically:
Our Electronic Payer ID: 76578 or via email to contact@solsticebenefits.com
DHMO Dental Claims can also be mailed to:
PO Box 21157
Eagan, MN 55121
Dental Claims Forms
Vision Claims
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
Short-Term & Long-Term Disability Claims
Group Disability and Life Contact Information
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: 607-773-2276
Mail: 225 S East Street, Suite 360; Indianapolis, IN 46202
Short and Long Term Disability Claims
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.
- Employee Statement [DIS-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.
- Spanish Employee Statement [DIS-101C-SP]
- Attending Physician’s Statement [DIS-102C]: This form is required and must be completed by your treating healthcare provider.
- Employer’s Statement [DIS-103C]: This form is required and must be completed by your employer.
- Supplementary Statement Claim Form [SSC-001C]: Submit this form to request an extension of disability benefits and provide updates on your medical condition and treatment.
- Authorization for the release of medical information [ADH-001C]: This form allows us to contact your health care provider in the event we need clarification or to request medical records.
- Authorization of Direct Deposit of Claim Payment [ADD-004C]: Complete this form and provide the necessary documentation if you would like to receive claim payments via direct deposit. (Note: direct deposit may not be available for all products/clients. If you have questions about the availability of direct deposit, please contact your assigned claim examiner.)
- IRS Form W-4S Request for Optional Federal Income Tax Withholding: Complete this form if you want optional federal income tax withheld from taxable benefit payments.
Group Life and AD&D Claims
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: 607-773-2276
- Mail: 225 S East Street, Suite 360; Indianapolis, IN 46202
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.
- Continuation of Life Application [CTL-101A]
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.
- Life Insurance Claim Form Waiver of Premium Employee Statement [LIW-001C]: 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.
- Attending Physician’s Statement [LIW-002C]: This form is required and must be completed by your treating healthcare provider.
- Employer’s Statement [LIW-003C]: This form is required and must be completed by your employer.
- Authorization for the release of medical information [ADH-001C]: This form allows us to contact your health care provider in the event we need clarification or to request medical records.
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 [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.
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.
- Proof of Loss and AD&D Employee Statement [POL-001C]: 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.
- Attending Physician’s Statement [POL-002C]: This form is required and must be completed by your treating healthcare provider.
- Employer’s Statement [POL-003C]: This form is required and must be completed by your employer.
- Authorization for the release of medical information [ADH-001C]: This form allows us to contact your health care provider in the event we need clarification or to request medical records.
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.
- Accelerated Death Benefit Application and Claim Form [ADB-001C]: This form contains sections that must be completed by you, your employer, and your treating healthcare provider.
- California Accelerated Death Benefit Application Form [ADB-001C-CA]: For California claims only
Group Accident Claims
Accident Forms
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. The completed form and any additional documentation noted as required must be submitted within 30 days of the date of accident/injury.
- Group Accident Employer Statement for Claims [GAC-102C]: This form is required and must be completed by your employer.
Paid Family Medical Leave (PFML) Claims
PFML Claim Forms
The following is a list of forms and documentation typically needed to file a claim for benefits under a Paid Family and Medical Leave policy.
- Ren PFML Application Form [PFML-001C]: This form is required for all PFML requests and must be completed by the employee and the employer. This form includes instructions for additional documentation that is required to be submitted with the application form. Missing or incomplete documentation will result in delays in processing the claim for benefits.
- Ren PFML Medical Certification Form [PFML-002C]: This form is required to be submitted with the PFML Application form if leave is being requested due to the employee’s own medical condition, a family member’s medical condition or to care for an injured military service member.
Additional Forms
- Authorization of Direct Deposit of Claim Payment [ADD-004C]: Complete this form and provide the necessary documentation if you would like to receive claim payments via direct deposit.
- IRS Form W-4S Request for Optional Federal Income Tax Withholding: Complete this form if you want optional federal income tax withheld from taxable benefit payments.
- Ren PFML Intermittent Absence Claim Form [PFML-003C]: Submit this form if you are taking intermittent time off under an approved PFML claim. To ensure timely processing of payments, submit the form at the end of each pay period during which intermittent absences were taken. The form must be signed by an authorized employer representative. The signature date must be on/after the last date of absence reported on the form. Only dates of absence that have already occurred are to be reported on this form. Future dates cannot be submitted or processed for payment.
