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UT: Forms - Dearborn Life Benefits

UT: Forms - Dearborn Life Benefits 2026

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The document is a Group Life Waiver of Premium Claim Form from the Life Insurance Company of New York, detailing the process for filing a claim for waiver of premium due to disability. It outlines eligibility criteria, required documentation, and instructions for completion by the employer, insured individual, and attending physician. The form emphasizes the need for proof of disability within one year and includes sections for personal information, medical history, and authorization for information release.

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Click ‘Get Form’ to open the UT: Forms - Dearborn Life Benefits in the editor.
Begin with Part 1, where the Employer/Administrator must provide group information, including Group Name, Group Number, and contact details. Ensure all fields are accurately filled out.
In Part 2, the Insured or their representative should complete personal details such as name, Social Security number, and address. Include information about the disability and treatment history.
For Part 3, the Attending Physician must fill out their section regarding the patient's condition and treatment. This includes diagnosis dates and any relevant medical history.
Review all sections for completeness and accuracy before submitting. Use our platform’s features to sign electronically if required.

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