LTD CLAIM FORM INSTRUCTIONS Please note the policy number for Long Term Disability (LTD) is VPL301475 Please fax completed claim forms and attachments (only) to 2672563519 or mail to: First Reliance Standard Life Insurance Company P 2026

1. Click 'Get Form' to open the LTD Claim Form in our editor.
2. Begin by entering your policy number, VPL301475, in the designated field at the top of the form.
3. Complete Section 1, the Employer's Statement. Ensure that all required information about the employer and employee is filled out accurately.
4. Move on to Section 3, where you will provide your personal details as the employee. Include your name, address, and social security number.
5. In Section 4, fill out your Employment and Education Information. Be thorough in detailing your educational background and work history.
6. Ensure that all sections are completed before signing and dating the Authorization for Use in Obtaining Information in Section 5.
7. Once completed, use our platform to fax your claim forms and attachments to 267-256-3519 or mail them to First Reliance Standard Life Insurance Company at P.O. Box 7749, Philadelphia, PA 19101-7749.

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