Claims Procedures

Notice of Claim

Notice of claim must be provided to Assurity within 20 calendar days after the loss starts by either contacting Assurity, as described below, or submitting necessary claims forms. If notice is not given within that time, it must be given as soon as reasonably possible.

Notice, including the insured’s name and policy number, may be sent to Assurity by one of the following:

When Assurity receives notice of claim, the necessary proof loss forms will be sent.

Notice may also be provided by submitting necessary claims forms. Forms are available on Assurity’s public site at http://www.assurity.com in the Customer Center by accessing the Customer Service Forms/Claim Forms section on the left.

Filing a Claim

In filing a claim with Assurity Life Insurance Company, the necessary proof of loss forms are as follows:

Claimant’s Statement - Form No. 01-012-02255

Employer’s Statement - Form No. 01-013-02255

Attending Physician’s Statement - Form No. 01-014-02255

Authorization Statement - Form No. varies by state

In filing a claim with Assurity Life Insurance Company of New York, the necessary proof of loss forms are as follows:

Claimant’s Statement - Form No. 01-012-02255 NY

Employer’s Statement - Form No. 01-013-02255 NY

Attending Physician’s Statement - Form No. 01-014-02255 NY

Authorization Statement - Form No. 80-500-05055 NY

Proof of loss must be returned to Assurity within 120 calendar days after loss. If not possible, the claim will not be reduced or denied for this reason if the proof is filed as soon as reasonably possible. In any event, the proof required must be given no later than one year from the time of loss unless the insured is legally incapacitated.

Claim forms may be returned to Assurity by the methods described above. If forms are emailed or faxed, please do not mail the original.