If You Received Your Coverage Through Work…
Disability Insurance Customer Support
800-894-4532
Mon. – Fri. – 8 am – 5 pm ET
groupclaims@renaissancefamily.com
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 well-being 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: 800-894-4532
Email: GroupClaims@RenaissanceFamily.com
Fax: 607-773-2276
Mail: PO Box 1596, Indianapolis, IN 46206
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 – All Other Conditions [DIS-102C]: This form is required for all conditions except pregnancy-related claims and must be completed by your healthcare provider.
- Attending Physician’s Statement – Pregnancy Disability [DIS-102C-PRG]: This form is required for pregnancy-related claims and must be completed by your 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.
