Life Insurance Help Center

GROUP MEMBER PORTAL
LIFE COVERAGE FAQS
CLAIMS INFORMATION & FORMS

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

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

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