Individual Claims Forms
Note: All forms are Adobe Acrobat Portable Document Files (PDFs). Click on the Adobe icon to receive the latest Acrobat Reader for free.
For all individual life death claims, we must have an original or certified death certificate.
Individual Life Death Claim Forms
Assignment of Life Insurance Proceeds
Authorization for Disclosure of Health and Other Information (HIPAA) – Claimant
Authorization for Disclosure of Health and Other Information (HIPAA) – Decedent
Children’s Affidavit for Dependent Rider
Collateral Assignee’s Agreement
Individual Life Insurance Contestable Death Claim Form
Individual Life Insurance Incontestable Death Claim Form
Waiver of Premium for Disability Claim Forms
Individual Accident Policy Claim Form
The Individual Claim Department may be contacted directly at:
- Security Mutual Life Insurance Company of New York
- Attn: Individual Claims
- P.O. Box 1625
100 Court Street
Binghamton, NY 13902-1625
For Individual Death Claims
- Telephone: 1-800-846-6305
- E-mail: [email protected]
- Fax: 1-607-338-7404
For Individual Accident Claims
- Telephone: 1-800-927-8846 Option 2
- E-mail: [email protected]
- Fax: 1-607-773-2276