Claim Forms
Dental, Vision, Life & Disability Forms
Review the information below to submit a claim form, as well as browse our available forms.
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:
For questions regarding your life and disability claim:
Email: groupclaims@renaissancefamily.com
Phone: 844-368-6485, Option #2
Dental Claim Form [D-101C]
Dental Claim Form Spanish [D-101C-SP]
Group Accident Claim Form [GAC-101C]
Group Accident Employer Statement for Claims [GAC-102C]
Group Accident Attending Physician Statement for Claims [GAC-103C]
Review common questions regarding our life claims:
Proof of Loss and AD&D [POL-001C]
Life and Accidental Death Claim Form [ADD-001C]
Life Insurance Claim Form Waiver of Premium [LIW-001C]
Accelerated Death Benefit Application and Claim Form [ADB-001C]
Life and Accident Group Insurance Beneficiary Form [BEN-104A]
Life and Accident Group Insurance Beneficiary Form (Spanish) [BEN-104A-SP]
Review common questions regarding short term and long term disability claims:
Short Term Disability Claim Form [STD-101C]
Long Term Disability Claim Form [LTD-101C]
Supplementary Statement of Claim Form [SSC-001C]
DBL-450 New York DBL Notice and Proof of Claim [DBL-002A-2019-NY]
DBL-451 New York DBL Notice of Total-Partial Rejection of Claim [DBL-003A-2019-NY]
DBL-PFL-009A New York DBL-PFL Admin Contacts [DBL-PFL-009A-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]
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]
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 Jersey Temp Disability Benefits Claim Form and Application [TDB-101C-NJ]
New Jersey Temp Disability Benefits Claim Form [TDB-102C-NJ]
New Jersey Temp Disability Benefits Contacts [TDB-003A-NJ]
New Jersey Temp Disability Benefits & Family Leave Benefits Admin Forms [TDB-FLB-001A-NJ]
New Jersey Family Leave Benefits Intermittent Leave Schedule Forms [FLB-001A-NJ]
New Jersey Family Leave Benefits Application and Claim Form [FLB-101C-NJ]
New Jersey TDB Application [TDB-App-DP1-12-ST]
New Jersey FLB Application [FDP-1 (R-1-12)]