Insurance Claims Forms

The following forms will assist you with the filing of a death claim:

• Death Claim Form

Form for all deaths - accidental or natural
• Living Benefit Options Claim Form

12 months life expectancy (Acclerated Benefits)
• Next of Kin Form
• Minor
  • Mode of Settlement Option Form
  • (Link) Guardianship Papers
  • (Link) Information regarding the location of the court closest to your home
  • Guardianship of the Estate forms

• Death Claim Form

Form for all deaths - accidental or natural
• Dismemberment Claim Form

Loss of part of the body due to an accident

• Philadelphia Cancer Claim Form
  • If you have Kaiser Permanente, please complete the Kaiser Authorization for Release of Information Form.
  • L.A. City Employee's Club Authorization For Release of Information Form


• Kanawha Cancer Claim Form
  • If you have Kaiser Permanente, please complete the Kaiser Authorization for Release of Information Form.
  • Kanawha's Authorization For Release of Information Form

Assurity

• Assurity Claim Forms


• Authorization to Assurity for Release of Info to City Employees Club


• Kaiser Authorization to Release of Information

PIC

• PIC Supplemental Disability Claim Form
  • If you have Kaiser Permanente, please complete the Kaiser Authorization for Release of Information Form.
  • L.A. City Employee's Club Authorization For Release of Information Form

• Employee Statement Form

To be completed by the Employee
• Physician Statement Form

To be completed by the Doctor’s office
• Employer Statement Forms - City

To be completed by the Payroll-Personnel Offices
• Employer Statement Forms - DWP

To be completed by the Payroll-Personnel Offices
• Supervisor Form

To be completed by the Supervisor
• Authorization to Release of Information

To be completed by employee
• Payroll Deduction Authorization Card


• Authorization to Release Information Form


• Kaiser's Authorization Form

• Long Term Care (LTC)
  • If you have Kaiser Permanente, please complete the Kaiser Authorization for Release of Information Form.
  • L.A. City Employee's Club Authorization For Release of Information Form


• Pet