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Forms

Claim forms require information to be provided by three parties: the insured employee/retired employee, the benefits coordinator and the attending practitioner. The insured employee/retired employee must complete the Employee's Statement and have the attending physician fully complete the Attending Practitioner's Statement. The benefits coordinator will forward the fully completed claim form along with any other required documents directly to the Fort Dearborn Life Insurance Company claims office.

Note: "Read Out Loud" is a Text-to-Speech tool that is built into the free Adobe Reader. Adobe Reader reads text contained within any of the PDF documents below. From the Adobe Reader "View" menu select "Read Out Loud" and then your reading preference ("Read This Page Only" or "Read To End of Document").

Employees

Retired Employees