Employer Forms

Forms may be downloaded by using Adobe Acrobat software. Once downloaded, forms should be completed, printed, and then mailed to Prudential's Group Insurance at the address indicated on each form. Obtain the plug-in and instructions for installation free of charge. Get Adobe Acrobat Reader.

Summary of Material Modifications
Effective August 1, 2006, Prudential's group disability claim operations has issued an updated description of the claims procedures that apply to group Short Term Disability and Long Term Disability claims. The revised description clarifies when a Short Term Disability or Long Term Disability claim is considered to have been filed, and restates our current process for determining benefits and for the processing of appeals of adverse claim determinations. If your Short Term Disability or Long Term Disability plan is subject to ERISA, your plan's Summary Plan Description needs to be amended to reflect the updated description of the claims procedures, and your plan's participants and beneficiaries need to be advised of those changes. Under ERISA rules, such notification must be provided within 210 days after the end of the plan year in which the change was effective. Insured plans can do this by distributing a paper or electronic version of the following Summary of Material Modifications (SMM) to each plan participant covered under the plan and to each plan beneficiary receiving benefits under the plan. ASO (Administrative Services Only) plans can use it as a guide for preparing their own SMM. Summary of Material Modification (SMM)


Billing

Roster Adjustment Form
NJEA and NJSA Roster Adjustment Form

General-Conversion
Notice of Conversion Privilege for Group Life Insurance
Canadian Residents Notice of Group Life Conversion Privilege
General Conversion Rates and Information (all states except FL)
General Conversion Rates and Information (FL only)
Long Term Disability Conversion Kit (residents of all states except VA and SD)
Long Term Disability Conversion Kit (residents of VA)
Residents of SD are not eligible for LTD conversion

General-Dependents Coverage
Notice of Change in Dependent Status for all products

Disability and Absence Claims
Initial Claim Package for Long Term Disability and Short Term Disability 
Job Description
Short Term Disability and Long Term Disability Claimant Statement
Social Security Authorization
Employer Statement
Attending Physician's Statement
Attending Physician's Statement (Spanish) 
Medical Authorization
Address Verification
Tax Notice
EFT Authorization
Psychotherapy Medical Authorization
FMLA Medical Certification-Care of Family Member
FMLA Medical Certification-Own Serious Health Condition
Disability and FMLA Physician Statement-Own Serious Health Condition
FMLA Medical Certification-Request for Military Exigency Leave
FMLA Medical Certification-Request for Care of Covered Service Member
FMLA Employee Rights and Responsibilities Under the Family and Medical Leave Act

NY State Mandated Disability (DBL)
Statement of Rights-Employee Claim Notice
Employer ID Card

Life Claims
Group Life Claim Form-all other employer contracts
Group Life Claim Form for Kentucky employer contracts only
Group Life Claim Form for Arkansas, North Dakota employer contracts only
Group Life Claim Form - New York, employer contracts only
Group Life Claim Form - Kansas, Alaska, employer contracts only
Group Life Claim Form - Minnesota, employer contracts only
Beneficiary Statement - New York 
Group Life Accidental Injury Claim Form
Group Life Claim Form for Total Disability Benefits - Employee Statement (Waiver of Premium)
Group Life Claim Form for Total Disability Benefits - Employer Statement (Waiver of Premium) 
Group Life Claim Form for Total Disability Benefits - Attending Physician's Statement (Waiver of Premium)

Claimant's Statement /Attending Physician Statement
Claim for Survivor

General-Enrollment
Group Life & Disability Enrollment/Change Card-approved in all states except NY, UT, and VA
Group Life & Disability Enrollment/Change Card-New York employer contracts only
Group Life & Disability Enrollment/Change Card-Virginia employer contracts only
Group Life Enrollment/Change Card-approved in all states except NY, UT, and VA
Group Disability Enrollment/Change Card-approved in all states except NY, UT, and VA

Group Life, Disability & Dental Enrollment/Change Form-approved in all states except NY
Group Life, Disability & Dental Enrollment/Change Form-approved in New York
Dental Enrollment/Change Form- approved in all states except NY and WA
Dental Enrollment/Change Form-New York employer contracts only
Dental Enrollment/Change Form-Washington employer contracts only
Employer Notification of Qualifying Event Under Cal-COBRA
California-COBRA Dental Election Form

Medical Underwriting for Life or Disability
 

Evidence of Insurability (EOI) Forms - English and Spanish Versions
The Prudential EOI process combines quick and easy initial screening with the ability to submit further evidence should an individual not clear the initial screening. Under the process, an individual who requires EOI initially completes a "short form." This form provides the initial screening. If the individual clears such screening, the application for coverage is approved. If the individual does not clear such screening, a "long form" may be completed. This form provides more detailed information.

To ensure compliance with state requirements, and to make the screening process as easy as possible, we have developed different versions of the short and long forms. Explanations of when certain forms should be used are provided below, along with links to the actual forms themselves.

English Short Forms for Life Only
These forms should be used when you as the employer offer voluntary or contributory life insurance (no disability). These are the forms that should be provided to employees who require EOI.

Short Form Health Questionnaire-All employer contract states except for those listed
Short Form Health Questionnaire-California employer contracts only
Short Form Health Questionnaire-Florida employer contracts only
Short Form Health Questionnaire-Idaho employer contracts only
Short Form Health Questionnaire-Kentucky employer contracts only
Short Form Health Questionnaire-Maine employer contracts only
Short Form Health Questionnaire-Maryland employer contracts only
Short Form Health Questionnaire-Massachusetts employer contracts only
Short Form Health Questionnaire-Minnesota employer contracts only
Short Form Health Questionnaire-Missouri employer contracts only
Short Form Health Questionnaire-Nebraska employer contracts only
Short Form Health Questionnaire-New Jersey employer contracts only
Short Form Health Questionnaire-New York employer contracts only
Short Form Health Questionnaire-Nevada employer contracts only
Short Form Health Questionnaire-North Carolina employer contracts only
Short Form Health Questionnaire-Texas employer contracts only
Short Form Health Questionnaire-Utah employer contracts only
Short Form Health Questionnaire-Vermont employer contracts only

English Short Forms for Life and Disability, or for Disability Only
These forms should be used whenever you offer a voluntary or contributory disability plan-either with or without life insurance.
Important Note: For cases sitused in CA and MA, you must use a long form.

Short Form Health Questionnaire-All employer contract states except for those listed
Short Form Health Questionnaire-Florida employer contracts only
Short Form Health Questionnaire-Idaho employer contracts only
Short Form Health Questionnaire-Kentucky employer contracts only
Short Form Health Questionnaire-Maine employer contracts only
Short Form Health Questionnaire-Maryland employer contracts only
Short Form Health Questionnaire-Minnesota employer contracts only
Short Form Health Questionnaire-Missouri employer contracts only
Short Form Health Questionnaire-Nebraska employer contracts only
Short Form Health Questionnaire-New Jersey employer contracts only
Short Form Health Questionnaire-New York employer contracts only
Short Form Health Questionnaire-Nevada employer contracts only
Short Form Health Questionnaire-North Carolina employer contracts only
Short Form Health Questionnaire-Texas employer contracts only
Short Form Health Questionnaire-Utah employer contracts only
Short Form Health Questionnaire-Vermont employer contracts only


English Long Forms
These forms are generally provided by Prudential directly to the applicants after we have received a short form that we are not able to approve. The forms for life and disability are the same. In the event that a participant has completed a short form and needs a copy of the long form to complete, you can provide the appropriate form to him/her. The cover page and sections of Part A of the form need to be completed, by you, prior to distributing to the employee/member.

Evidence of Insurability Instructions
Evidence of Insurability-All employer contract states except for those listed
Evidence of Insurability-Arizona employer contracts only
Evidence of Insurability-Florida employer contracts only
Evidence of Insurability-Louisiana employer contracts only
Evidence of Insurability-Maine employer contracts only
Evidence of Insurability-Michigan employer contracts only
Evidence of Insurability-Minnesota employer contracts only
Evidence of Insurability-Missouri employer contracts only
Evidence of Insurability-Montana employer contracts only
Evidence of Insurability-New Jersey employer contracts only
Evidence of Insurability-New York employer contracts only
Evidence of Insurability-Vermont employer contracts only
Evidence of Insurability-Virginia employer contracts only
Evidence of Insurability-Wisconsin employer contracts only

 
Spanish Short Forms for Life Only

These forms should be used when you as the employer offer voluntary or contributory life insurance (no disability). These are the forms that should be provided to employees who require EOI.

Spanish Short Form Health Questionnaire-All employer contract states except for those listed
Spanish Short Form Health Questionnaire-California employer contracts only
Spanish Short Form Health Questionnaire-Florida employer contracts only
Spanish Short Form Health Questionnaire-Idaho employer contracts only
Spanish Short Form Health Questionnaire-Kentucky employer contracts only
Spanish Short Form Health Questionnaire-Maine employer contracts only
Spanish Short Form Health Questionnaire-Maryland employer contracts only
Spanish Short Form Health Questionnaire-Massachusetts employer contracts only
Spanish Short Form Health Questionnaire-Minnesota employer contracts only
Spanish Short Form Health Questionnaire-Missouri employer contracts only
Spanish Short Form Health Questionnaire-Nebraska employer contracts only
Spanish Short Form Health Questionnaire-New Jersey employer contracts only
Spanish Short Form Health Questionnaire-New York employer contracts only
Spanish Short Form Health Questionnaire-Nevada employer contracts only
Spanish Short Form Health Questionnaire-North Carolina employer contracts only
Spanish Short Form Health Questionnaire-Texas employer contracts only
Spanish Short Form Health Questionnaire-Utah employer contracts only
Spanish Short Form Health Questionnaire-Vermont employer contracts only
Spanish Short Form Health Questionnaire-Washington employer contracts only

Spanish Short Forms for Life and Disability, or for Disability Only
These forms should be used whenever you offer a voluntary or contributory disability plan-either with or without life insurance.
Important Note: For cases sitused in CA and MA, you must use a long form.

Spanish Short Form Health Questionnaire-All employer contract states except for those listed
Spanish Short Form Health Questionnaire-Florida employer contracts only
Spanish Short Form Health Questionnaire-Idaho employer contracts only
Spanish Short Form Health Questionnaire-Kentucky employer contracts only
Spanish Short Form Health Questionnaire-Maine employer contracts only
Spanish Short Form Health Questionnaire-Maryland employer contracts only
Spanish Short Form Health Questionnaire-Minnesota employer contracts only
Spanish Short Form Health Questionnaire-Missouri employer contracts only
Spanish Short Form Health Questionnaire-Nebraska employer contracts only
Spanish Short Form Health Questionnaire-New Jersey employer contracts only
Spanish Short Form Health Questionnaire-New York employer contracts only
Spanish Short Form Health Questionnaire-Nevada employer contracts only
Spanish Short Form Health Questionnaire-North Carolina employer contracts only
Spanish Short Form Health Questionnaire-Texas employer contracts only
Spanish Short Form Health Questionnaire-Utah employer contracts only
Spanish Short Form Health Questionnaire-Vermont employer contracts only
Spanish Short Form Health Questionnaire-Washington employer contracts only

Spanish Long Forms
These forms are generally provided by Prudential directly to the applicants after we have received a short form that we are not able to approve. The forms for life and disability are the same. In the event that a participant has completed a short form and needs a copy of the long form to complete, you can provide the appropriate form to him/her. The cover page and sections of Part A of the form need to be completed, by you, prior to distributing to the employee/member.

Spanish Evidence of Insurability-All employer contract states except for those listed
Spanish Evidence of Insurability-Arizona employer contracts only
Spanish Evidence of Insurability-Florida employer contracts only
Spanish Evidence of Insurability-Louisiana employer contracts only
Spanish Evidence of Insurability-Maine employer contracts only
Spanish Evidence of Insurability-Michigan employer contracts only
Spanish Evidence of Insurability-Minnesota employer contracts only
Spanish Evidence of Insurability-Missouri employer contracts only
Spanish Evidence of Insurability-Montana employer contracts only
Spanish Evidence of Insurability-New Jersey employer contracts only
Spanish Evidence of Insurability-New York employer contracts only
Spanish Evidence of Insurability-Vermont employer contracts only
Spanish Evidence of Insurability-Virginia employer contracts only
Spanish Evidence of Insurability-Washington employer contracts only
Spanish Evidence of Insurability-Wisconsin employer contracts only

General-Portability
Group Term Life Portability Election Form-Plan A
Group Term Life Portability Election Form-Plan A - New York employer contracts only
Johnson & Johnson AD&D Portability

General-Discontinuation
Notice of Discontinuance of Group Life or Disability Insurance

General Forms
Census Data Form - Dental
Census Data Form
Client Information Form
Group Insurance Internet Services Sign-up Form