National Benefit Life

Insurance Forms

Policy Change Forms

Change of Ownership

Click to print form
Change of Ownership Form

How is this used?
To correct, change or name a new owner or joint owner.

Signature Requirements
Current owner and new owner should sign form.

Mail Form to:
National Benefit Life Insurance Company
Attn: Policy Owner Services
One Court Square
Long Island City, NY 11120-0001
Change of Beneficiary


Click to print form
Change of Beneficiary Form

How is this used?
Change the beneficiary of your policy with this easy to use form.

Signature Requirements
Policy owner must sign form
*If there is an irrevocable beneficiary their signature is also required

Mail Form to:
National Benefit Life Insurance Company
Attn: Policy Owner Services
One Court Square
Long Island City, NY 11120-0001
Affidavit of Small Estate - Owner ISACH08


Click to print form
Affidavit of Small Estate - Owner ISACH08

How is this used?
Only complete if current owner is deceased and did not leave a probate estate.

Signature Requirements
Small Estate Administrator should sign form and provide death certificate of previous owner.

Mail Form to:
National Benefit Life Insurance Company
Attn: Policy Owner Services
One Court Square
Long Island City, NY 11120-0001
Change of Name Statement


Click to print form
Change of Name Statement

How is this used?
To correct or change the name of owner or insured

Signature Requirements
Current owner should sign form.

Mail Form to:
National Benefit Life Insurance Company
Attn: Policy Owner Services
One Court Square
Long Island City, NY 11120-0001
Change of Address - ISACH07


Click to print form
Change of Address - ISACH07

How is this used?
To correct or change current address on file.

Signature Requirements
Current owner should sign form.

Mail Form to:
National Benefit Life Insurance Company
Attn: Policy Owner Services
One Court Square
Long Island City, NY 11120-0001
Reinstatement Forms - NYL-87 B and Und. Rein. 001.11/91 Life


Click to print form
New York Reinstatement Form - NYL-87 B
Und. Rein. 001.11/91 Life - All states *except* New York


How is this used?
Complete to reinstate lapsed policy.

Signature Requirements
Current owner and insured should sign form.

Mail Form to:
National Benefit Life Insurance Company
Attn: Policy Owner Services
One Court Square
Long Island City, NY 11120-0001
Duplicate Policy - NO Form required


Duplicate Policy - No Form required

How do I request a duplicate policy?
Write to us at the address below to request a copy of your contract.

Signature Requirements
Policy owner must sign the written request.

Mail Request to:
National Benefit Life Insurance Company
Attn: Policy Owner Services
One Court Square
Long Island City, NY 11120-0001
Pre-Authorized Check Plan Request (PAC) - NYL-21


Click to print form and Instruction Page
Pre-Authorized Check Plan Request (PAC) - NYL-21
EXCLUDES Universal Life Policies and Annuity Contracts

How is this used?
For automatic drafting of Life Insurance premium from checking account.

Signature Requirements
Account holder must sign.

Mail Form to:
National Benefit Life Insurance Company
Attn: Policy Owner Services
One Court Square
Long Island City, NY 11120-0001
Pre-Authorized Check Plan - CHANGE OF BANK (PAC) - NYL-21


Click to print form and Instruction Page
Pre-Authorized Check Plan - CHANGE OF BANK (PAC) - NYL-21
EXCLUDES Universal Life Policies and Annuity Contracts

How is this used?
To change a bank or account number from previously set-up check plan.

Signature Requirements
Account holder must sign.

Mail Form to:
National Benefit Life Insurance Company
Attn: Policy Owner Services
One Court Square
Long Island City, NY 11120-0001
Electronic Payment Request (EP)


Electronic Payment Request (EP) - No FORM required

How is this used?
Your insurance premium can be paid electronically using your bank’s online bill pay service 24 hrs a day, 7 days a week.

Signature Requirements
Visit your banks website for details on how to set up electronic payments. Please include your policy # including leading zeros when setting up your electronic payment.

Mail Form to:
National Benefit Life Insurance Company
Attn: Policy Owner Services
One Court Square
Long Island City, NY 11120-0001

Insurance Claim Forms

Life Claim Form: DCL-10: Claimant’s Statement

Claimant’s Statement
(Click to Print Form)

How is this used?
Complete when reporting the death of an insured.

Signature Requirements
Beneficiary/ies must sign and date form and have their signature notarized. Please return the form with a certified copy of the death certificate and the original policy contract.

Mail Form to:
National Benefit Life Insurance Company
Attn: Claims Department
One Court Square
Long Island City, NY 11120-0001

Life Claim Form: Affidavit of Small Estate - Claims ISACHO8A

Affidavit of Small Estate - Claims ISACHO8A
(Click to Print Form and Instruction Page )

How is this used?
To verify decedent left no probate estate and claim rights to benefits payable if beneficiary is deceased.

Signature Requirements
Recipient of proceeds must sign, and signatures must be notarized.

Mail Form to:
National Benefit Life Insurance Company
Attn: Claims Department
One Court Square
Long Island City, NY 11120-0001
Life Claim Form: Terminal Illness Claim Form (NY Only)

Terminal Illness Claim Form (NY Only)

How is this used?
To report a claim for a portion of death benefit based on a diagnosis of a terminal medical condition.

Signature Requirements
Policy Owner and/or insured must sign, physician must sign and form must be notarized.

Mail Form to:
National Benefit Life Insurance Company
Attn: Claims Department
One Court Square
Long Island City, NY 11120-0001
Life Claim Form: FOR WAIVER OF PREMIUM AND DISABILITY INCOME CLAIMS - Claimant’s Disability Statement Form DCL 23

FOR WAIVER OF PREMIUM AND DISABILITY INCOME CLAIMS - Claimant’s Disability Statement Form DCL 23

Claimant’s Disability Statement Form DCL 23

(Select issue State)

How is this used?
To file the initial claim for waiver of premium or disability income benefits.

Signature Requirements
Policy Owner and Attending Physician must sign.

Mail Form to:
National Benefit Life Insurance Company
Attn: Claims Department
One Court Square
Long Island City, NY 11120-0001
Life Claim Form: FOR WAIVER OF PREMIUM AND DISABILITY INCOME CLAIMS - Claimant’s Final or Intermediate Disability Statement DCL-24W

FOR WAIVER OF PREMIUM AND DISABILITY INCOME CLAIMS - Claimant’s Final or Intermediate Disability Statement

Claimant’s Disability Statement Form DCL-24W

(Select issue State)

How is this used?
To report medical status for continuation of disability income or waiver of premium benefits.

Signature Requirements
Policy Owner and Attending Physician must sign.

Mail Form to:
National Benefit Life Insurance Company
Attn: Claims Department
One Court Square
Long Island City, NY 11120-0001

Accident & Health Forms
For use with Accident and Health Policies:

Accident & Health Form: Health Insurance Claim Form - AHC 33


Health Insurance Claim Form - AHC 33

(Select issue State)

How is this used?
To report a claim for a Major Medical expense reimbursement.

Signature Requirements
Policy Owner and Attending Physician must sign.

Mail Form to:
National Benefit Life Insurance Company
Attn: Claims Department
One Court Square
Long Island City, NY 11120-0001
Accident & Health Form: Accident and Health Claim Form - DMG-024



Accident and Health Claim Form - DMG-024

(Select issue State)

How is this used?
To report a claim for daily hospital indemnity payment.

Signature Requirements
Policy Owner and Attending Physician must sign.

Mail Form to:
National Benefit Life Insurance Company
Attn: Claims Department
One Court Square
Long Island City, NY 11120-0001
Confidential Communication Request Form (NY) - for Victims of Domestic Violence and Endangered Individuals

Click to print form
Confidential Communication Request form

How is this used?
To receive claim-related information by alternative means or
at alternative locations if disclosing claim-related information
could endanger the person.

Signature Requirements
Policy owner must sign form

Mail Form to:
National Benefit Life Insurance Company
One Court Square
Long Island City, NY 11120