Filing A Claim
Basic Instructions:
Claim forms require information from three parties:
- the insured employee/retiree
- the benefits coordinator
- the attending practitioner
The employee/retiree is responsible for:
- Completing the employee section and signing
- Sending the form to their Benefits Coordinator to
complete the Employers section
- Sending the form to their doctor to complete the
Attending Practitioners Statement
- Sending the completed form to Dearborn National
(FDL)
Reference the claim form or visit our FAQs for more
detailed information on filing a claim for Life Insurance, Disability, Accelerated Life, or Extended Life Insurance.
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Application PDF's 
