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Long Term Disability Benefits Claim Packet Instructions The Standard Life Insurance Company of New York[removed]Tel[removed]Fax PO Box 5031 White Plains NY 10602
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Document Date: 2014-07-29 15:12:24

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ZIP City / New York / /

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STANDARD INSURANCE COMPANY / Release Psychotherapy Notes Standard Insurance Company / Release Information Standard Insurance Company / The Standard Life Insurance Company / For Standard Insurance Company / Immune Deficiency Syndrome / /

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USD / /

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Labor Issues / Debt Financing / M&A / /

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Hospital Name Address From Through Reason / College Graduate / Any hospital / Hospital Address SNY / Hospital If / /

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licensed insurance / insurance / insurance benefits / insurance action / legal services / fraudulent insurance act / /

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Social Security Administration / Railroad Retirement Board / Any / Any hospital / Workers’ Compensation Board / /

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Psychotherapist / /

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Position

Attorney / Psychiatrist / ABSENCE MANAGEMENT PROGRAM ADMINISTRATOR / plan administrator / Absence Manager / benefit administrator / Signature Date Physician / Date Physician / York Long Term Disability Insurance Attending Physician / Address Physician / illness Physician / accountant / or tax preparer / Psychologist / Clinical Social Worker / physician / Representative / Manager / 24 months / rehabilitation counselor / organization or program / legal representative / Attending Physician / /

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New Mexico / /

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