Forms

Short & Long Term Disability/Paid Family & Medical Leave forms

Short-Term Disability

Long-Term Disability

Colorado Family and Medical Leave Insurance (FAMLI) 

Connecticut Paid Family and Medical Leave

Massachusetts Paid Family and Medical Leave

New Jersey Temporary Disability Benefits (TDB)

New York Disability Benefits Law (DBL) and Paid Family Leave (PFL)

Please choose the form associated with the state in which your employer is headquartered. This may or may not coincide with your state of residence, however please only use the form corresponding to the state in which your employer is headquartered.

California
Florida
Louisiana

  • Online Web Form - Use this electronic submission form for a quicker response. (Google Chrome only)

  • Printable PDF Form - To print, complete and return via email and mail.

Maine
Minnesota
Missouri
Montana
New Hampshire
New Jersey
New Mexico
New York and Puerto Rico
Ohio
Utah
Virginia
All other states

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GE-6377780.1 (02/2024) (Exp. 02/2026)