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Forms

Life Insurance

Accidental Death & Dismemberment

Accidental Death & Dismemberment Claim Form

Short-Term Disability

Short-Term Disability Claim Instructions
Sick Leave and Salary Confirmation Statement — To be completed by the Benefits Office.
Authorization to Exchange Medical Information for Claim Administration — To be sent to claim intake specialist

Long-Term Disability

Long-Term Disabilty Employee Claim Form
Long-Term Disability Employer Claim Form
Long-Term Disability Conversion Kit
Sick Leave and Salary Confirmation Statement — To be completed by the Benefits Office.
Authorization to Exchange Medical Information for Claim Administration — To be sent to claim intake specialist

Life, AD&D and Disability products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.