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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 opens in new window.
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) PDF opens in new window .
Billing
Roster Adjustment Form PDF opens in new window
General-Conversion
- Notice of Conversion Privilege for Group Life Insurance PDF opens in new window
- Canadian Residents Notice of Group Life Conversion Privilege PDF opens in new window
- Group Long Term Disability Insurance Conversion Plan Kit PDF opens in new window
Residents of SD are not eligible for LTD conversion
General-Critical Illness & Voluntary Accident Continuation
- Group Accident & Critical Illness Continuation Form PDF opens in new window
- Group Accident Continuation Form PDF opens in new window
- Group Critical Illness Continuation Form PDF opens in new window
Disability and Absence Claims (Includes Massachusetts Paid Family & Medical Leave)
- Initial Claim Package for Long Term Disability and Short Term Disability PDF opens in new window
- Initial Claim Package for Long Term Disability and Short Term Disability (Advise To Pay) PDF opens in new window
- Job Description PDF opens in new window
- Short Term Disability and Long Term Disability Claimant Statement PDF opens in new window
- Social Security Authorization PDF opens in new window
- Employer Statement PDF opens in new window
- Attending Physician's Statement PDF opens in new window
- Attending Physician's Statement (Spanish) PDF opens in new window
- Medical Authorization PDF opens in new window
- Address Verification PDF opens in new window
- Tax Notice PDF opens in new window
- EFT Authorization PDF opens in new window
- Psychotherapy Medical Authorization PDF opens in new window
- Certification of Health Care Provider for Family Member’s Serious Health Condition PDF opens in new window
- Certification of Health Care Provider for Employee Serious Health Condition PDF opens in new window
- Certification of Health Care Provider for Employee’s Serious Health Condition for Disability and Family Leave Act PDF opens in new window
- Family & Medical Certification Request for Military Exigency Leave PDF opens in new window
- Family & Medical Certification Request for Care of Covered Service Member PDF opens in new window
- FMLA Employee Rights and Responsibilities Under the Family and Medical Leave Act PDF opens in new window
- Authorization for Release of Health-Related Information for Own Serious Health Condition PDF opens in new window
- Authorization for Release of Health-Related Information for Care of Family Member PDF opens in new window
NY State Mandated Disability (DBL)
- Statement of Rights-Employee Claim Notice PDF opens in new window
- Employer ID Card PDF opens in new window
NY Paid Family Leave (PFL)
- Release of Personal Health Information Under the NY Paid Family Leave (PFL) Law (Based on Form PFL-3) PDF opens in new window
- Request for NY Paid Family Leave (PFL) Bonding Certification (Based on Form PFL-2) PDF opens in new window
- Request for NY Paid Family Leave (PFL) Health Care Provider Certification For Care Of Family Member With Serious Health Condition (Based on Form PFL-4) PDF opens in new window
- Request for NY Paid Family Leave (PFL) Military Qualifying Event (Based on Form PFL-5) PDF opens in new window
- Request for NY Paid Family Leave (PFL) (Based on Form PFL-1) – Employer Version PDF opens in new window
- Request for NY Paid Family Leave (PFL) (Based on Form PFL-1) – Employee Version PDF opens in new window
- NY Paid Family Leave (PFL) Voluntary Tax Withholding Request PDF opens in new window
- NY Paid Family Leave (PFL) Statement of Rights PDF opens in new window
Life Claims
- Group Life Claim Form - all other employer contracts PDF opens in new window
- Group Life Claim Form - KY employer contracts only PDF opens in new window
- Group Life Claim Form - AR & ND employer contracts only PDF opens in new window
- Group Life Claim Form - AK, KS, MN, NY employer contracts only PDF opens in new window
- Group Life Accidental Injury Claim Form PDF opens in new window
- Group Life Claim Form for Total Disability Benefits - Employer Statement (Waiver of Premium) PDF opens in new window
- Claim for Survivor PDF opens in new window
General-Enrollment
- Group Life and AD&D Enrollment Form for Utah Residents PDF opens in new window
- Group Life and Disability Enrollment Form for Utah Residents PDF opens in new window
- Group Life and AD&D Enrollment Form for New York Contract Situs and Residents PDF opens in new window
- Group Life and Disability Enrollment Form for New York Contract Situs and Residents PDF opens in new window
- Group Life and AD&D Enrollment Form for All Contract Situs States Except New York and All Residents Except New York and Utah PDF opens in new window
- Group Life and Disability Enrollment Form for all Contract Situs except New York and all Residents Except New York and Utah PDF opens in new window
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 PDF opens in new window
- Short Form Health Questionnaire-Alaska employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Arizona employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Arkansas employer contracts only PDF opens in new window
- Short Form Health Questionnaire-California employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Florida employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Illinois employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Kansas employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Kentucky employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Louisianna employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Maine employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Maryland employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Minnesota employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Missouri employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Montana employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Nebraska employer contracts only PDF opens in new window
- Short Form Health Questionnaire-New Hampshire employer contracts only PDF opens in new window
- Short Form Health Questionnaire-New Jersey employer contracts only PDF opens in new window
- Short Form Health Questionnaire-New Mexico employer contracts only PDF opens in new window
- Short Form Health Questionnaire-New York employer contracts only PDF opens in new window
- Short Form Health Questionnaire-North Carolina employer contracts only PDF opens in new window
- Short Form Health Questionnaire-North Dakota employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Ohio employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Oregon employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Texas employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Utah employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Vermont employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Virginia employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Washington DC employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Washington employer contracts only PDF opens in new window
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.
- Short Form Health Questionnaire-All employer contract states except for those listed PDF opens in new window
- Short Form Health Questionnaire-Alaska employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Arizona employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Arkansas employer contracts only PDF opens in new window
- Short Form Health Questionnaire-California employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Florida employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Illinois employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Kansas employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Kentucky employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Louisianna employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Maine employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Maryland employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Minnesota employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Missouri employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Montana employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Nebraska employer contracts only PDF opens in new window
- Short Form Health Questionnaire-New Hampshire employer contracts only PDF opens in new window
- Short Form Health Questionnaire-New Jersey employer contracts only PDF opens in new window
- Short Form Health Questionnaire-New Mexico employer contracts only PDF opens in new window
- Short Form Health Questionnaire-New York employer contracts only PDF opens in new window
- Short Form Health Questionnaire-North Carolina employer contracts only PDF opens in new window
- Short Form Health Questionnaire-North Dakota employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Ohio employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Oregon employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Texas employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Utah employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Vermont employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Virginia employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Washington DC employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Washington employer contracts only PDF opens in new window
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 PDF opens in new window
- Evidence of Insurability-All employer contract states except for those listed PDF opens in new window
- Evidence of Insurability-Arizona employer contracts only PDF opens in new window
- Evidence of Insurability-Florida employer contracts only PDF opens in new window
- Evidence of Insurability-Louisiana employer contracts only PDF opens in new window
- Evidence of Insurability-Maine employer contracts only PDF opens in new window
- Evidence of Insurability-Michigan employer contracts only PDF opens in new window
- Evidence of Insurability-Minnesota employer contracts only PDF opens in new window
- Evidence of Insurability-Missouri employer contracts only PDF opens in new window
- Evidence of Insurability-Montana employer contracts only PDF opens in new window
- Evidence of Insurability-New Jersey employer contracts only PDF opens in new window
- Evidence of Insurability-New York employer contracts only PDF opens in new window
- Evidence of Insurability-Vermont employer contracts only PDF opens in new window
- Evidence of Insurability-Virginia employer contracts only PDF opens in new window
- Evidence of Insurability-Wisconsin employer contracts only PDF opens in new window
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.
- Short Form Health Questionnaire-All employer contract states except for those listed PDF opens in new window
- Short Form Health Questionnaire-Alaska employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Arizona employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Arkansas employer contracts only PDF opens in new window
- Short Form Health Questionnaire-California employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Florida employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Illinois employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Kansas employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Kentucky employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Louisianna employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Maine employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Maryland employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Minnesota employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Missouri employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Montana employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Nebraska employer contracts only PDF opens in new window
- Short Form Health Questionnaire-New Hampshire employer contracts only PDF opens in new window
- Short Form Health Questionnaire-New Jersey employer contracts only PDF opens in new window
- Short Form Health Questionnaire-New Mexico employer contracts only PDF opens in new window
- Short Form Health Questionnaire-New York employer contracts only PDF opens in new window
- Short Form Health Questionnaire-North Carolina employer contracts only PDF opens in new window
- Short Form Health Questionnaire-North Dakota employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Ohio employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Oregon employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Texas employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Utah employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Vermont employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Virginia employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Washington DC employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Washington employer contracts only PDF opens in new window
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.
- Short Form Health Questionnaire-All employer contract states except for those listed PDF opens in new window
- Short Form Health Questionnaire-Alaska employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Arizona employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Arkansas employer contracts only PDF opens in new window
- Short Form Health Questionnaire-California employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Florida employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Illinois employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Kansas employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Kentucky employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Louisianna employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Maine employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Maryland employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Minnesota employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Missouri employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Montana employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Nebraska employer contracts only PDF opens in new window
- Short Form Health Questionnaire-New Hampshire employer contracts only PDF opens in new window
- Short Form Health Questionnaire-New Jersey employer contracts only PDF opens in new window
- Short Form Health Questionnaire-New Mexico employer contracts only PDF opens in new window
- Short Form Health Questionnaire-New York employer contracts only PDF opens in new window
- Short Form Health Questionnaire-North Carolina employer contracts only PDF opens in new window
- Short Form Health Questionnaire-North Dakota employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Ohio employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Oregon employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Texas employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Utah employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Virginia employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Vermont employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Washington DC employer contracts only PDF opens in new window
- Short Form Health Questionnaire-Washington employer contracts only PDF opens in new window
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 PDF opens in new window
- Spanish Evidence of Insurability-Arizona employer contracts only PDF opens in new window
- Spanish Evidence of Insurability-Florida employer contracts only PDF opens in new window
- Spanish Evidence of Insurability-Louisiana employer contracts only PDF opens in new window
- Spanish Evidence of Insurability-Maine employer contracts only PDF opens in new window
- Spanish Evidence of Insurability-Michigan employer contracts only PDF opens in new window
- Spanish Evidence of Insurability-Minnesota employer contracts only PDF opens in new window
- Spanish Evidence of Insurability-Missouri employer contracts only PDF opens in new window
- Spanish Evidence of Insurability-Montana employer contracts only PDF opens in new window
- Spanish Evidence of Insurability-New Jersey employer contracts only PDF opens in new window
- Spanish Evidence of Insurability-New York employer contracts only PDF opens in new window
- Spanish Evidence of Insurability-Vermont employer contracts only PDF opens in new window
- Spanish Evidence of Insurability-Virginia employer contracts only PDF opens in new window
- Spanish Evidence of Insurability-Washington employer contracts only PDF opens in new window
- Spanish Evidence of Insurability-Wisconsin employer contracts only PDF opens in new window
General-Portability
- Group Term Life Portability Election Form-Plan A PDF opens in new window
- Group Term Life Portability Election Form-Plan A - New York employer contracts only PDF opens in new window
General Forms
- Client Information Form PDF opens in new window
- Group Insurance Internet Services Sign-Up Form 5 Users PDF opens in new window
- Group Insurance Internet Services Sign-Up Form 10 Users PDF opens in new window
- Group Insurance Internet Services Sign-Up Form 20 Users PDF opens in new window
- Group Insurance Internet Services Sign-Up Form 50 Users PDF opens in new window
Waiver of Premium
- Waiver of Premium - Attending Physician's Statement GI/ILI Combo Form PDF opens in new window
- Waiver of Premium Authorization Form GI/ILI Combo Form PDF opens in new window
- Waiver of Premium Claimant Form GI/ILI Combo Form PDF opens in new window
- Waiver of Premium - Employer Statement PDF opens in new window
For Compliance only California COA #1179 NAIC Code #68241
103918-0807