Policy Forms
Fillable Forms are provided for your convenience. Please print the completed form and provide an original handwritten ("wet") signature before submitting. Electronic signatures are not accepted.
Policy Change Forms
Click to print form
Change of Ownership Form (PDF)
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
30-30 47th Avenue, Suite 625
Long Island City, NY 11101
Click to print form
Change of Beneficiary Form (PDF)
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
30-30 47th Avenue, Suite 625
Long Island City, NY 11101
Click to print form
Affidavit of Small Estate - Owner ISACH08 (PDF)
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
30-30 47th Avenue, Suite 625
Long Island City, NY 11101
Click to print form
Change of Name Statement (PDF)
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
30-30 47th Avenue, Suite 625
Long Island City, NY 11101
Click to print form
Change of Address - ISACH07 (PDF)
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
30-30 47th Avenue, Suite 625
Long Island City, NY 11101
Click to print form
New York Reinstatement Form - NYL-87 B (PDF)
Und. Rein. 001.11/91 Life - All states *except* New York (PDF)
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
30-30 47th Avenue, Suite 625
Long Island City, NY 11101
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
30-30 47th Avenue, Suite 625
Long Island City, NY 11101
Click to print form and Instruction Page
Pre-Authorized Check Plan Request (PAC) - NYL-21 (PDF)
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
30-30 47th Avenue, Suite 625
Long Island City, NY 11101
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
30-30 47th Avenue, Suite 625
Long Island City, NY 11101
Insurance Claim Forms
| Policies Greater than 2-years | Policies Less than 2-years old |
| DCL-10 Generic (PDF) | DCL-10 Generic (PDF) |
| DCL-10 California (PDF) | DCL-10 California (PDF) |
| DCL-10 New York (PDF) | DCL-10 New York (PDF) |
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
30-30 47th Avenue, Suite 625
Long Island City, NY 11101
Terminal Illness Claim Form (NY Only) (PDF)
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
30-30 47th Avenue, Suite 625
Long Island City, NY 11101
| Report of Claim - Claimant's Disability Statement |
Waiver of Premium Report of Claim - Claimant's Disability Statement |
| DCL-23 Generic (PDF) | DCL-23W Generic (PDF) |
| DCL-23 California (PDF) | DCL-23W California (PDF) |
| DCL-23 New York (PDF) | DCL-23W New York (PDF) |
| Claimant's Supplementary or Final Disability Statement | Waiver of Premium Claimant's Supplementary or Final Disability |
| DCL-24 Generic (PDF) | DCL-24W Generic (PDF) |
| DCL-24 California (PDF) | DCL-24W California (PDF) |
| DCL-24 New York (PDF) | DCL-24W New York (PDF) |
Accident and Health and Hospital Cash Forms
For use with Accident and Health Policies:
Click to print form
Confidential Communication Request form (PDF)
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.
Revocation of Confidential Communication Request Form
How is this used?
Individual customers who wish to revoke previously submitted confidential communication requests may do so in writing with a Confidential Communication Revocation Request Form or simply by sending a letter.
Signature Requirements
Policy owner must sign form
Mail Form to:
National Benefit Life Insurance Company
Attn: Claims Department
30-30 47th Avenue, Suite 625
Long Island City, NY 11101
National Benefit Life does not exclude from coverage a covered health care service or procedure delivered to a covered patient as a telemedicine medical service or a telehealth service solely because the covered health care service or procedure is not provided through an in-person consultation. The policies and payment practices of National Benefit Life do not distinguish telemedicine medical services and telehealth services from such services delivered in-person to the covered patient.
| Accident and Health | Hospital Cash Form |
| AHC33 Generic (PDF) | DMG-024 Generic (PDF) |
| AHC33 California (PDF) | DMG-024 California (PDF) |
| AHC33 New York (PDF) | DMG-024 New York (PDF) |
Click to print form
Health Designee Form (NY)