Disability Benefit Lump Sum Payment Request Form

Disability Benefit Lump Sum Payment Request Form
Use this form to request a one-time lump sum disability benefit payment and provide the details needed to process the request.
Claimant Information
Full name
First NameMiddle NameLast Name
Date of birth
MonthDayYear
Date
Preferred contact method
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Email address
example@example.com
Mailing address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Case or reference number
Benefit Request Details
Type of Disability Benefit Requested
Reason for Lump Sum Payment Request
Other
Claim or Benefit Start Date
MonthDayYear
Date
Relationship to Claimant
Supporting Explanation for the Request
Payment Delivery Preferences
Preferred Payment Delivery Method
Other Approved Delivery Method
Mailing Address for Payment Delivery
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred Payee Name
Supporting Documentation and Declarations
Supporting Documents
Cancelof
Should be Empty: