Forms
| Title | Purpose | Number |
|---|---|---|
| PFML Care of Family Member Packet (WA) | Complete this packet to apply for Washington Paid Family and Medical Leave to care for a family member with a serious health condition. | SI 21265-WA |
| Authorization to Release Health-Related Information | Authorize The Standard to release dental and/or vision insurance information to a designated recipient. | 11702 |
| Health Maintenance Screening Benefit Claim Form (Outside NY) | Use this form if you have the Health Maintenance Screening Benefit through your employer. | 17430 |
| Accident Benefit Claim Form (Outside NY) | Use this form to file an Accident insurance claim. | 17502 |
| Critical Illness Benefit Claim Form (Outside NY) | Use this form to file a Critical Illness insurance claim. | 17503 |
| Specified Disease Benefit Claim Form (In Vermont) | Use this form to file a Specified Disease insurance claim. For use in Vermont only. | 17503 VT |
| Hospital Indemnity Benefit Claim Form (Outside NY) | Use this form to file a Hospital Indemnity insurance claim. | 17504 |
| Waiver of Premium Claim Packet (Outside NY) | If you have a life insurance policy issued outside of New York that includes the Waiver of Premium benefit, you can use this packet to request the waiver. | SI 1284 |
| Balanced Care Vision Plan III Claim | Use this form to initiate an eye care claim. | SI 14068 |
| Vision Claim Form (Outside NY) | Use this form to initiate a vision claim. | SI 14068 |
| Vision Claim Form (Spanish - Outside NY) | Use this form to initiate a vision claim (Spanish). | SI 14068 SPU |
| Eye Med Vision Out of Network Claim | Used to initiate an out of network eye care claim. | SI 14070 |
| VSP Vision Out of Network Claim | Used to request out of network eye care expense reimbursement. | SI 14071 |
| Short Term Disability Claim Packet (Outside NY) | Use this packet to file a claim for a Short Term Disability plan issued outside of the state of New York. | SI 2047 |
| PFML Bonding Leave Packet (MA) | Complete this packet to apply for Massachusetts Paid Family and Medical Leave to bond with a newborn, a newly adopted or fostered child. | SI 21264-MA |
| PFML Bonding Leave Packet (WA) | Complete this packet to apply for Washington Paid Family and Medical Leave to bond with a newborn, a newly adopted or fostered child. | SI 21264-WA |
| PFML Care of Family Member Packet (MA) | Complete this packet to apply for Massachusetts Paid Family and Medical Leave to care for a family member with a serious health condition. | SI 21265-MA |
| PFML Own Serious Health Condition Packet (MA) | Complete this packet to apply for Massachusetts Paid Family and Medical Leave for your own serious health condition. | SI 21266-MA |
| PFML Own Serious Health Condition Packet (WA) | Complete this packet to apply for Washington Paid Family and Medical Leave for your own serious health condition. | SI 21266-WA |
| PFML Military Leave Packet (MA) | Complete this packet to apply for Massachusetts Paid Family and Medical Leave to assist family members due to another family member’s active military duty or impending active duty abroad. | SI 21267-MA |
| PFML Military Leave Packet (WA) | Complete this packet to apply for Washington Paid Family and Medical Leave to assist family members due to another family member’s active military duty or impending active duty abroad. | SI 21267-WA |
| Long Term Disability Claim Packet (Outside NY) | Use this packet to file a claim for a Long Term Disability plan issued outside of the state of New York. | SI 3379 |
| Dental Claim (Outside NY) | Use this form to report a treatment plan and to initiate a dental claim. | SI 3943 |
| State Disability Claim Packet (NJ) | Use this packet to file a claim through a New Jersey State Disability plan. | SI 9426-RCO |
| EFT Setup for Long Term Disability Claim Payments | Used to request the electronic funds transfer (EFT) of Long Term Disability claim payments. | SI 9571 |
| Waiver of Premium Claim Packet (In NY) | If you have a life insurance policy issued in New York that includes the Waiver of Premium benefit, you can use this packet to request the waiver. | SNY 1284 |
| Vision Claim Form (In NY) | Use this form to initiate a vision claim. For use in New York only. | SNY 14069 |
| Vision Claim Form (Spanish - In NY) | Use this form to initiate a vision claim (Spanish). For use in New York only. | SNY 14069 SPU |
| Health Maintenance Screening Benefit Claim Form (In NY) | Use this form if you have the Health Maintenance Screening Benefit through your employer. For use in New York only. | SNY 17430 |
| Accident Benefit Claim Form (In NY) | Use this form to file an Accident insurance claim. For use in New York only. | SNY 17502 |
| Specified Disease Benefit Claim Form (In NY) | Use this form to file a Specified Disease insurance claim. For use in New York only. | SNY 17503 |
| Hospital Indemnity Benefit Claim Form (In NY) | Use this form to file a Hospital Indemnity insurance claim. For use in New York only. | SNY 17504 |
| PFL Bonding Leave Packet (In NY) | Use this packet for file a claim for bonding leave under Paid Family Leave in New York. | SNY 19378 |
| PFL Care of Family Member Packet (In NY) | Use this packet for file a claim for care of family member leave under Paid Family Leave in New York. | SNY 19379 |
| PFL Military Leave Packet (In NY) | Use this packet for file a claim for military exigency leave under Paid Family Leave in New York. | SNY 19380 |
| Short Term Disability Claim Packet (In NY) | Use this packet to file a claim for a Short Term Disability plan issued in the state of New York. | SNY 2047 |
| Long Term Disability Claim Packet (In NY) | Use this packet to file a claim for a Long Term Disability plan issued in the state of New York. | SNY 3379 |
| Dental Claim (In NY) | Use this form to report a treatment plan and to initiate a dental claim. For use in New York only. | SNY 3943 |
| State Disability Claim Packet (NY) | Use this packet to file a claim through a New York State Disability plan. | SNY 9457 |
| EFT Setup for Long Term Disability Claim Payments (In NY) | Used to request the electronic funds transfer (EFT) of Long Term Disability claim payments. | SNY 9571 |
