Group Disability Insurance
Claim Instructions
Instructions to File a Claim for Disability Benefits
1. Complete all Sections of the Employee Statement.
2. Read the Tax Notice and complete it for voluntary Federal Income Tax withholding from disability benefit payments.
3. Ask your Doctor to complete an Attending Physician's Statement.
4. Submit these completed forms according to the directions you received from your Benefits Office.
The Prudential Insurance Company of America
Disability Management Services
P0 Box 13480, Philadelphia, PA 19101
Voice: 1-800-842-1718
Facsimile: 1-877-889-4885
For your protection, certain state laws require the following to appear on this form:
California Residents Notice - Section 1879.2 of the California Statutes regarding Insurance Fraud requires us to inform you of
the following law: "Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may
be subject to fines and confinement in state prison."
Colorado Residents Notice - Section 10-1 -1 27(7)(a) of the Colorado Statutes regarding Insurance Fraud requires us to
inform you of the following law: "It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance
company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of
insurance, civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or
misleading information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant
with regards to a settlement of award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the
Department of Regulatory Agencies."
Delaware Residents Notice - Section 11.913(b) of the Delaware Statutes regarding Insurance Fraud requires us to inform you
of the following law: "Any person who knowingly, and with intent