Claim and Policy Forms
Below you can find forms to make changes to information regarding your policy. Please file your claim online quickly, simply and easily.These forms are for use if you’re not able to file online.
Please follow directions on the form, complete and mail, email or fax to us.
- Ownership change
- Birthdate correction
- Name change
- Update Social Security number
- Additional policy contact
- Removal of benefits
- Third party authorization
- Beneficiary change
- Designate a trust as your beneficiary
- New York Domestic Violence Notice
Leaving your current job? Take your policy with you with direct billing.
- Pay your bill online
- Note: all outstanding premium must be paidprior to setting upautomatic payments.
- Direct billing - Automatic bank draft/EFT
- Authorization Agreement for Electronics Funds Transfer
Universal Life Insurance:
- Request a partial surrender
- Request a loan
Learn more about how changes can affect your Universal Life policy.
Claim benefits for an injury caused by a covered accident.
Download form
Claim Submissions:AccidentClaimsVB@trustmarkbenefits.com
Claim Related Questions:ClaimContactVB@trustmarkbenefits.com
Phone: 877-201-9373 x45704
Fax: 508-853-2867
Claim benefits for a physical or wellness screening test such as (see your policy for details):
- Mammogram
- Cholesterol Test
- Chest X-Ray
- Vaccination
Download form
Claim Submission:RiderClaimsVB@trustmarkbenefits.com
Claim Related Questions:ClaimContactVB@trustmarkbenefits.com
Phone: 877-201-9373 x45704
Fax: 508-471-3208
Claim benefits for a health screening test such as (see your policy for details):
- Mammogram
- Cholesterol Test
- Chest X-Ray
- Pap Smear
Download form
Claim Submission:RiderClaimsVB@trustmarkbenefits.com
Claim Related Questions:ClaimContactVB@trustmarkbenefits.com
Phone: 877-201-9373 x45704
Fax: 508-471-3208
BEFORE YOU GO TO THE DOCTOR...
Some claims have forms that need to be signed by your doctor. You can bring them with you so that you’re all set when you start your claim. If you want to print these and take them with you, here are the most common:
- Attending Physician Statement (For your initial claim)
- Attending Physician Statement (For an Additional Sickness Rider claim)
- Attending Physician Statement (For a Specified Illness Rider claim)
- Attending Physician Statement (For Waiver of Premium)
- Physician Certification (For a Caregiver Benefit claim)
Learn about Best Doctors®, which gives you access to second opinions, medical advice and more at no extra cost.Learn more
Phone: 866-904-0910
Claim benefits when you have been diagnosed with a heart attack, stroke or cancer.
Download form
Claim Submissions:DICIClaimsVB@trustmarkbenefits.com
Claim Related Questions:ClaimContactVB@trustmarkbenefits.com
Phone: 877-201-9373 x45708
Fax: 508-853-2767
Claim benefits when you are unable to perform two activities of daily living (ADLs) due to sickness for at least 90 continuous days such as (see your policy for details):
- Eating
- Bathing
- Getting dressed
- Toileting
- Transferring in and out of bed
Download form
Claim Submissions:DICIClaimsVB@trustmarkbenefits.com
Claim Related Questions:ClaimContactVB@trustmarkbenefits.com
Phone: 877-201-9373 x45708
Fax: 508-853-2767
Claim benefits when giving care to an eligible family member. For example:
- Home healthcare
- Homemaking assistance (light housekeeping, shopping and meal preparation, laundry, medication management or bill paying)
- Transportation to medical services
Download form
Claim Submissions:DICIClaimsVB@trustmarkbenefits.com
Claim Related Questions:ClaimContactVB@trustmarkbenefits.com
Phone: 877-201-9373 x45708
Fax: 508-853-2767
Waive your Critical HealthEvents policy premiums if you are out of work for 6 months due to a covered disability.
Download form
Claim Submissions:DICIClaimsVB@trustmarkbenefits.com
Claim Related Questions:ClaimContactVB@trustmarkbenefits.com
Phone: 877-201-9373 x45708
Fax: 508-853-2767
Claim benefits surrounding specific illnesses such as (see your policy for details):
- Complications of diabetes
- Renal failure
- Organ failure
Download Form
Claim Submissions:DICIClaimsVB@trustmarkbenefits.com
Claim Related Questions:ClaimContactVB@trustmarkbenefits.com
Phone: 877-201-9373 x45708
Fax: 508-853-2767
Claim benefits for a health screening test or preventive services, such as (see your policy for details):
- Mammogram
- Colonoscopy
- Pap Smear
- EKG
Download form
Claim Submissions:RiderClaimsVB@trustmarkbenefits.com
Claim Related Questions:ClaimContactVB@trustmarkbenefits.com
Phone: 877-201-9373 x45704
Fax: 508-853-2757
BEFORE YOU GO TO THE DOCTOR...
Some claims have forms that need to be signed by your doctor. You can bring them with you so that you’re all set when you start your claim. If you want to print these and take them with you, here are the most common:
- Attending Physician Statement
Learn about Best Doctors®, which gives you access to second opinions, medical advice and more at no extra cost.Learn more
Phone: 866-904-0910
Claim benefits when you have been diagnosed with a covered critical illness or cancer.
Download form
Claim Submission:DICIClaimsVB@trustmarkbenefits.com
Claim Related Questions:ClaimContactVB@trustmarkbenefits.com
Phone: 877-201-9373 x45708
Fax: 508-853-2757
Claim benefits for a health screening test such as (see your policy for details):
- Mammogram
- Cholesterol Test
- Chest X-Ray
- Pap Smear
Download form
Claim Submission:RiderClaimsVB@trustmarkbenefits.com
Claim Related Questions:ClaimContactVB@trustmarkbenefits.com
Phone: 877-201-9373 x45704
Fax: 508-471-3208
BEFORE YOU GO TO THE DOCTOR...
Some claims have forms that need to be signed by your doctor. You can bring them with you so that you’re all set when you start your claim. If you want to print these and take them with you, here are the most common:
- Attending Physician Statement (For disability claims)
- Attending Physician Statement (For pregnancy claims)
- Attending Physician Statement (For continuance of a disability claim)
Claim benefits when you have been out of work due to a covered pregnancy.
Download form
Claim Submission:DICIClaimsVB@trustmarkbenefits.com
Claim Related Questions:ClaimContactVB@trustmarkbenefits.com
Phone: 877-201-9373 x45711
Fax: 508-853-2757
For benefits when you have been out of work due to a covered non-pregnancy related disability.
Initial Claim - Download Form
Continuing Claim - Download Form
Claim Submission:DICIClaimsVB@trustmarkbenefits.com
Claim Related Questions:ClaimContactVB@trustmarkbenefits.com
Benefits when you have been in the hospital.
Download form
Claim Submissions:HospitalClaimsVB@trustmarkbenefits.com
Claim Related Question:ClaimContactVB@trustmarkbenefits.com
Phone: 877-201-9373 x45704
Fax: 508-853-2867
Benefits for care outside the hospital, such as:
- Diagnostic lab tests
- X-Ray, CT, MRI or Pet Scan
- Surgery conducted as outpatient
- Immediate Care at ER or Urgent Care
- Transport by Ambulance
- Rehabilitation Services
Download Form
Claim Submissions:HospitalClaimsVB@trustmarkbenefits.com
Claim Related Question:ClaimContactVB@trustmarkbenefits.com
Phone: 877-201-9373 x45704
Fax: 508-853-2867
Claim benefits for a routine wellness screening test or preventive services, such as (see your policy for details):
- Mammogram
- Colonoscopy
- Pap Smear
- EKG
Download Form
Claim Submission:RiderClaimsVB@trustmarkbenefits.com
Claim Related Questions:ClaimContactVB@trustmarkbenefits.com
Phone: 877-201-9373 x45704
Fax: 508-471-3208
BEFORE YOU GO TO THE DOCTOR...
Some claims have forms that need to be signed by your doctor. You can bring them with you so that you’re all set when you start your claim. If you want to print these and take them with you, here are the most common:
- Attending Physician Statement (For early benefits)
- Attending Physician Statement (For Waiver of Premium)
Claim Submission:LifeClaimsVB@trustmarkbenefits.com
Claim Related Questions:ClaimContactVB@trustmarkbenefits.com
Contact Via Email
Phone: 877-201-9373 x45750
Fax: 508-853-0310
Download Form
Please note that in certain situations, additional proof of loss may be required. Call for assistance if you have questions regarding your specific situation.
Phone: 877-201-9373 xt. 45750
Claim benefits when covered long-term care or home health care services are being received.
Download Form
Claim a portion of your life insurance when you have received a terminal diagnosis.
Download form
Start waiving your life insurance policy premiums if you are out of work due to a covered disability.
Download form
Continue waiving your life insurance policy premiums if you are out of work due to a covered disability.
Download form
Claim Related Questions:ClaimContactVB@trustmarkbenefits.com
Fax: 508-853-0310
Claim benefits when covered long-term care or home health care services are being received.
Download form
Claim a portion of your life insurance when you have received a terminal diagnosis.
Download form
Start waiving your life insurance policy premiums if you are out of work due to a covered disability.
Download form
Continue an existing waiver of premium for your life insurance policy.
Download form
To report the death of a loved one.
Note: To obtain the appropriate claim form, please contact us.
Customer Care: (800) 918-8877 or send a message to the Customer Care team. Customer care professionals are available Monday through Friday from 7amto 6 pmCT.
New York Universal Life PoliciesCustomer Care: (866) 949-6036 or send a message to the NY Customer Care team. Customer care professionals are available Monday through Friday from 7 amto 4 pmCT (8 am to 5 pm ET).
Trustmark Voluntary Benefit Solutions, Inc. is a subsidiary of Trustmark Mutual Holding Company. Insurance products are underwritten by Trustmark Insurance Company or, for life insurance products in NY, Trustmark Life Insurance Company of New York.
