Claim Form Instructions Claim forms require information from three parties: the insured employee/retiree the benefits coordinator the attending practitioner The employee 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.