Group Long-Term Disability Claim Form - Dearborn Life Benefits 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with the 'Employer Report of Claim' section. Fill in the employee's name, Social Security number, and contact details. Ensure you attach a detailed job description and any necessary documentation.
3. Next, complete the 'Application for LTD Benefits - Employee Instructions'. Provide your personal information, including date of birth and employment details. Sign the authorization to allow BCBSIL to access your medical records.
4. For the 'Attending Physician Statement', ensure your physician fills out all required fields accurately. This includes diagnosis, treatment history, and functional capacity assessments.
5. If opting for direct deposit, complete the 'Direct Deposit Authorization Agreement' section with your bank details. Make sure to sign and date this form.
6. Review all sections for completeness before submitting. Use our platform’s features to save your progress and ensure all attachments are included.

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