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Employer Forms

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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

Residents of SD are not eligible for LTD conversion

General-Critical Illness & Voluntary Accident Continuation

Disability and Absence Claims (Includes Massachusetts Paid Family & Medical Leave)

NY State Mandated Disability (DBL)

 

NY Paid Family Leave (PFL)

Life Claims

General-Enrollment

Please contact your Account Executive or Account Manger to obtain state specific enrollment forms according to eligibility rules and the customized suite of Prudential Group Insurance Products.

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.

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.

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.

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 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.

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.

General-Portability

General Forms

Waiver of Premium

For Compliance only California COA #1179 NAIC Code #68241

103918-0807

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