Employer Forms

Forms may be downloaded here and viewed 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 Readeropens 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. Administrative Services Only (ASO) plans can use it as a guide for preparing their own SMM. 

Supplemental Health Benefits (for groups issues 7/1/19 and later)
Billing 
Disability, Absence and State Paid-Leave Claims
General
Life Claims
Medical Underwriting for Life or Disability
NY Paid Family Leave (PFL)
NY State-Mandated Disability (DBL)
Waiver of Premium


Supplemental Health Benefits

 


Billing

Roster Adjustment Form PDF fileDownloads a pdf file

Notice of Discontinuation of Group Life and/or Disability Insuranceopens a PDF in new tab


Disability, Absence and State Paid-Leave Claim

 


General

Residents of SD are not eligible for LTD conversion

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.


Life Claims

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.

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.

These forms should be used whenever you offer a voluntary or contributory disability plan-either with or without life insurance.

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.

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.

These forms should be used whenever you offer a voluntary or contributory disability plan-either with or without life insurance.

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.


NY Paid Family Leave (PFL)

 


NY State-Mandated Disability (DBL)

 


Waiver of Premium

 

California COA #1179 NAIC Code #68241

For Compliance Use Only:103918-0807