To File a Disability Claim:

There are three forms that need to be completed to submit a disability claim for benefits.

 If you are an Employee, please complete these 3 forms:

1. 1. Insured’s Statement and Release of Information Authorization 
   2. Attending Physician’s Statement 
   3. Employer’s Statement 

 

If you are an Independent Contractors or Self Employed, please complete these 3 forms:

1. 1. Insured’s Statement and Release of Information Authorization 
   2. Attending Physician’s Statement 
   3. Employer’s Statement

The Insured should complete the entire Insured’s Statement, sign the Release of Information Authorization, and return to:

Everest Reinsurance Company c/o Allied National – Claims Administrator
PO Box 29186
Shawnee Mission, KS 66201-9186

In addition, the Insured should provide the Attending Physician’s Statement, including patient name, policy number, and Date of Birth, to the Disabling Physician for completion.  The Disabling Physician should then complete the form and send the completed form directly to Everest Reinsurance Company c/o Allied National – Claims Administrator.

Lastly, the Insured should provide the Employer’s Statement (with Insured’s policy number) to their Employer for completion.  The Employer should then send the completed form to Everest Reinsurance Company c/o Allied National – Claims Administrator.. 

 

All three forms must be sent directly to Everest Reinsurance Company c/o Allied National – Claims Administrator for the claims review process to begin. SUBMISSION OF AN INCOMPLETE OR UNSIGNED CLAIM FORM MAY RESULT IN A DELAY IN PROCESSING YOUR CLAIM. 

Please feel free to contact Everest Reinsurance Company c/o Allied National – Claims Administrator at 800-825-7531, if you have any questions. 

To download these directions, click here.