Claim Forms
Download a Claim Form
Participating dentists will submit your claim for you. However, if you choose a nonparticipating dentist, download and submit our claim form.
You or your dentist should send your claims to:
Renaissance
PO Box 17250
Indianapolis, IN 46217
Attn: Claims Department
Your VSP Doctor will submit claims on your behalf. To submit an Out-Of-Network claim, visit:
To obtain or submit your life and disability claim:
Email: claims@renaissancefamily.com
Phone: 844-368-6485, Option #2
State-Specific Forms
Below you will find links to state-specific forms:
DLB-450 New York DBL Notice and Proof of Claim [DBL-002A-2018-NY]
DBL-451 New York DBL Notice of Total-Partial Rejection of Claim [DBL-003A-2018-NY]
DB-271S New York DBL Statement of Rights [DBL-007A-2018-NY]
New York DBL Admin Contacts [DBL-009A-NY]
New York DBL Admin Forms [DBL-010A]
Group DBL-PFL Application [DBL-101A-2018-NY]
New York DBL-PFL Admin Contacts Combo [DBL-PFL-009A-NY]
New York DBL and PFL Admin Forms Combo [DBL-PFL-010A]
New York PFL Schedule of Benefits [PFL-001A-NY]
PFL-1 and PFL-2 New York PFL Bonding [PFL-002A-2018-NY]
PFL-1 and PFL-3 New York PFL For Family Member [PFL-003A-2018-NY]
PFL-1 and PFL-5 New York PFL Military [PFL-004A-2018-NY]
PFL-CR-001 New York PFL Total-Partial Denial [PFL-005A-2018-NY]
New York DBL-PFL Benefits Time-off Verification [PFL-006A-NY]
PFL-271S New York PFL Statement of Rights [PFL-007A-2018-NY]
PFL-WAIVER New York PFL Employee Opt-Out [PFL-008A-2018-NY]
PFL-1 through PFL-4 New York PFL Claim Form [PFL-0234C-2018-NY]