Claim Forms

You or your dentist should send your claims to:

Renaissance
PO Box 17250
Indianapolis, IN 46217
Attn: Claims Department

NOTE: If the member number on your ID card is a six-digit number starting with one, please dial 800-894-4532 for eligibility and customer support.

For questions regarding your dental claim:

claims@renaissancefamily.com
888-358-9484

For Solstice DHMO dental claims:

If the dental office is submitting electronically:
Our Electronic Payer ID: 76578 or via email to contact@solsticebenefits.com

DHMO Dental Claims can also be mailed to:
P.O. Box 2057
Farmington Hills, MI 48333

Dental Claim Form [D-101C]
Dental Claim Form Spanish [D-101C-SP]

Your VSP Doctor will submit claims on your behalf. To submit an Out-Of-Network claim, you can contact VSP:

www.vsp.com

800-877-7195

The Renaissance Life and Disability claims team understands how important compassionate support and timely claims processing is to the peace of mind and financial wellbeing of employees and their families facing major life events such as disability or the death of a loved one.

This page contains forms and information about the claims process for our group life and disability products offered to employees through their employer sponsored benefit plans.

Contact Information

• LIFE/DI CLAIMS CUSTOMER SERVICE: 844-368-6485
• EMAIL: GroupClaims@RenaissanceFamily.com
• FAX TO: 607-773-2276
• MAIL: 2 Court St. Suite 102, Binghamton, NY 13901

Submit your disability claim as soon as it becomes clear that you will be off work longer than the elimination period specified in your policy. Please use the following forms to apply for group short or long term disability benefits.

• Employee Statement [DIS-101C]: This form is required and must be completed by the employee. If the employee is unable to complete the form, a representative may complete the form on their behalf.
  • Spanish Employee Statement [DIS-101C-SP]
• Attending Physician’s Statement [DIS-102C]: This form is required and must be completed by your treating healthcare provider.
• Employer’s Statement [DIS-103C]: This form is required and must be completed by your employer.
• Supplementary Statement Claim Form [SSC-001C]: Submit this form to request an extension of disability benefits and provide updates on your medical condition and treatment.
• Authorization for the release of medical information [ADH-001C]: This form allows us to contact your health care provider in the event we need clarification or to request medical records.
• Authorization of Direct Deposit of Claim Payment [ADD-004C]: Complete this form and provide the necessary documentation if you would like to receive claim payments via direct deposit. (Note: direct deposit may not be available for all products/clients. If you have questions about the availability of direct deposit, please contact your assigned claim examiner.)
• IRS Form W-4S Request for Optional Federal Income Tax Withholding: Complete this form if you want optional federal income tax withheld from taxable benefit payments.

Additional information:

• Short Term Claim FAQ Flyer
• Long Term Claim FAQ Flyer

Continuation of Life Coverage during Disability

If you stop work due to disability (including Workers’ Comp) and have exhausted or are not eligible for federal/state family medical leave, contact your employer immediately to discuss how this impacts any group term life coverage you may have been enrolled in. Please refer to your certificate of insurance for time limits to apply for continued life coverage during disability. If a continuation application is not submitted timely, coverage terminates as of the date of disability or the end of approved federal/state family medical leave, whichever is later. To apply for continuation of coverage during disability, submit the following form.

• Continuation of Life Application [CTL-101A]

Life Waiver of Premium during Disability

In addition to the option to continue coverage during disability, your policy may also include a Waiver of Premium benefit. Waiver of Premium provisions typically require that:

• Continuation of life coverage during disability must be approved by Renaissance and you must continue to remit premium payments to Renaissance until a Waiver of Premium claim determination is made
• Total Disability (as defined in the policy) must begin before reaching the age limit specified in the policy
• Total Disability (as defined in the policy) must continue for the minimum amount of time specified in the policy

To apply for Waiver of Premium, submit the following forms as soon as it is clear you will be continuously disabled longer than the period specified in the Waiver of Premium provision of your policy. Waiver of Premium claims should be submitted no later than 12 months after your date of disability.

• Life Insurance Claim Form Waiver of Premium Employee Statement [LIW-001C]: This form is required and must be completed by the employee. If the employee is unable to complete the form, a representative may complete the form on their behalf.
• Attending Physician’s Statement [LIW-002C]: This form is required and must be completed by your treating healthcare provider.
• Employer’s Statement [LIW-003C]: This form is required and must be completed by your employer.
• Authorization for the release of medical information [ADH-001C]: This form allows us to contact your health care provider in the event we need clarification or to request medical records.

Death

The following is a list of forms and documentation typically needed to file a death claim. Additional information may be requested by Renaissance as needed depending on the specifics of the claim.

• Life and Accidental Death Claim Form Employee Statement [ADD-001C]: This form is required. For death of the employee, the form should be completed by the claimant/beneficiary. For death of a spouse/covered dependent, the form should be completed by the employee.
• Employer’s Statement [ADD-005C]: This form is required and must be completed by the employer. The employer should attach copies of all beneficiary designation forms and changes, the most recent payroll record for one full pay period prior to the employee’s last day or date of death and a copy of the employee’s original enrollment form.
• Death certificate: A final certified copy of the death certificate or other equivalent legal documentation is required and should be submitted with the claim form.
• For Accidental Death please provide any of the listed documentation that is available:
  • Autopsy report
  • Police/accident report
  • Newspaper articles
• Funeral Home Assignment form [FAL-001C]: This form is optional and should be completed if the beneficiary wishes to assign all or part of the benefit to cover funeral expenses. A copy of the itemized funeral bill should be submitted with this form.

Additional information:

• Life Claims FAQ

Accidental Dismemberment

The following is a list of forms and documentation typically needed to file a claim for dismemberment benefits under a group life policy.

• Proof of Loss and AD&D Employee Statement [POL-001C]: This form is required and must be completed by the employee. If the employee is unable to complete the form, a representative may complete the form on their behalf.
• Attending Physician’s Statement [POL-002C]: This form is required and must be completed by your treating healthcare provider.
• Employer’s Statement [POL-003C]: This form is required and must be completed by your employer.
• Authorization for the release of medical information [ADH-001C]: This form allows us to contact your health care provider in the event we need clarification or to request medical records.

Accelerated Death

If your group life policy includes an Accelerated Death Benefit provision for advanced partial payment upon diagnosis of a terminal illness, submit the following claim forms. Please refer to the policy certificate for additional information and limitations applicable to the accelerated death benefit.

• Accelerated Death Benefit Application and Claim Form [ADB-001C]: This form contains sections that must be completed by you, your employer, and your treating healthcare provider.

PLEASE NOTE: The following forms are subject to strict regulatory oversight and may be revised without notice. Please visit this site to retrieve current versions of claim forms for each claim submitted. Please do not save or print large quantities of forms downloaded from this site for future use. Outdated claim forms may be returned with instructions to complete the most current version approved by the state insurance department.

Disability Benefits (NY DBL)

To apply for New York State disability benefits, submit the below claim form. Do not submit this form before your first date of disability. You must submit your completed claim form within 30 calendar days after your first day of disability to avoid losing benefits. This form has a section to be filled out by your health care provider (Part B), and a section to be completed by your employer (Part C). Before providing the form to your health care provider and employer, fill out your section and make a copy to keep. The health care provider is required to return the form to you with Part B completed within seven days. If there is a delay in the health care provider completing Part B, you must wait to submit the form to Renaissance. If Part B is not complete (or has incomplete answers) there may be delay in the payment of benefits. Your employer is required to return the form to you with Part C completed within three business days. If there is a delay in obtaining Part C from your employer and both Part A and Part B are complete, you do not have to wait to proceed, you should send the form to Renaissance. Keep a copy of all forms and documents for your records.

• DBL-450 New York DBL Notice and Proof of Claim 

Paid Family Leave Benefits (NY PFL)

To apply for New York Paid Family leave select the appropriate claim forms packet based on your reason for taking leave.

• New York PFL Bonding PFL-1 and PFL-2 
• PFL-1 and PFL-3 New York PFL For Family Member
• New York PFL Military PFL-1 and PFL-5

Additional Forms:

• New York DBL-PFL Benefits Time-off Verification [PFL-006A-NY]: Have your employer submit this form if you are receiving PTO, vacation pay, or other pay from your employer.
• Intermittent Paid Family Leave Schedule [PFL-006A]: Have your employer submit this form if you are taking intermittent time off under PFL. This form must be submitted after an absence has occurred.
• IRS Form W-4S Request for Optional Federal Income Tax Withholding: Complete this form if you want optional federal income tax withheld from taxable benefit payments.

Additional Information:

• http://www.wcb.ny.gov/content/main/DisabilityBenefits/employee-disability-benefits.jsp
• https://paidfamilyleave.ny.gov/

PLEASE NOTE: The following forms are subject to strict regulatory oversight and may be revised without notice. Please visit this site to retrieve current versions of claim forms for each claim submitted. Please do not save or print large quantities of forms downloaded from this site for future use. Outdated claim forms may be returned with instructions to complete the most current version approved by the state insurance department.

Disability Benefits (NJ TDB)

To apply for New Jersey State disability benefits, submit the below claim form no later than 30 days after the date you become disabled.

• New Jersey Temp Disability Benefits Claim Form [TDB-101C-NJ]

Family Leave Benefits (NJ FLB)

To apply for New Jersey State family leave benefits, submit the below claim form no later than 30 days after your first date of leave.

• NJ Family Leave Benefits Claim Form [FLB-101C]

Additional Forms:

• Optional Tax Withholding IRS Form W-4S: Complete this form if you want optional federal income tax withheld from taxable benefit payments.

Additional Information:

• https://www.myleavebenefits.nj.gov/

The following is a list of forms and documentation typically needed to file a claim for benefits under a group accident policy.

• Group Accident Claim Form [GAC-101C]: This form is required and must be completed by the employee. If the employee is unable to complete the form, a representative may complete the form on their behalf.
• Group Accident Attending Physician Statement for Claims [GAC-103C]: This form is required and must be completed by your treating healthcare provider.
• Group Accident Employer Statement for Claims [GAC-102C]: This form is required and must be completed by your employer.
• Spouse/Adult Dependent signature forms [GAC-104C]: This form is required if the claim is for Spouse, Domestic Partner, or Dependent Child 18 years of age or older.
• Copy of birth or adoption papers: This is required if the claim is for a dependent child.
• Itemized medical bills incurred as a result of the accident: Copies of itemized billing are required that indicate the diagnosis, individual services received (i.e. X-ray, MRI, dates of actual physical therapy, etc.), and actual charges. General balance due notices are not sufficient.
• Police report: This is required if injury was a result of a motor vehicle accident and for any incidents investigated by any law enforcement agency.