Disability Claims Forms

NEW YORK DISABILITY/PAID FAMILY LEAVE CLAIMS RELATED TO COVID-19

If you are filing for disability or paid family leave for yourself due to COVID-19, please complete this form:

Request for COVID-19 Quarantine DB/PFL – Self (Form SCOVID19)

If you are filing for paid family leave due to the disability of a minor dependent child due to COVID-19, please complete this form:

Request for COVID-19 Quarantine PFL – Child (Form CCOVID19)

Additional information for employees to obtain a mandatory order of quarantine or isolation can be found here:

Obtaining An Order – NYS Department of Health

Other important information related to New York State Paid Family Leave is available here:

https://paidfamilyleave.ny.gov/new-york-paid-family-leave-covid-19-faqs

NEW YORK DISABILITY/PAID FAMILY LEAVE CLAIMS NOT RELATED TO COVID-19

Please submit the following forms within 30 days of the start of the disability:

Notice and Proof of Claim for Disability Benefits 

Statement of Rights

If your disability policy includes an In-Hospital Rider and the claim involves a hospital stay, please also submit the form below:

In-Hospital Statement of Claim

If your disability policy includes an Accidental Death & Dismemberment Rider and the claim involves such an scenario, please also submit the form below:

Accidental Death & Dismemberment Claim Form

For claims involving paid family leave, please submit the following forms within 30 days of the expected leave (as known):

Paid Family Leave – Bonding with New Child

Paid Family Leave – Care for Family Member

Paid Family Leave – Military

Submit Forms To

  • claimsintake@guard.com
  • 570-825-0611 (fax)
  • Berkshire Hathaway GUARD
    P.O. Box 1368
    Wilkes-Barre, PA 18703-1368

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