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Group Insurance Please send the completed form and all attachments to: The Prudential Insurance Company of America Group Life Claim Division P.O. Box 8517 Philadelphia, PA 19176 Group Accidental Injury
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Security Number 2 Claimant s Accident Date (mm YYY) Location of Claim (Street, Number of Accident) Date of Accident (mm dd YYY) Claimant s Accident Condition, If any Claimant s Age (mm YYY) Claimant s Disability Information (If applicable) Is you would like to make a disability claim in conjunction with your personal injury claim, please complete the claim form online and send the required documentation. You will be required to complete the online application for a Disability Insurance claim. If you have any questions about disability insurance, please call a specialist at or in your own time. Information in a claim can not be released. The Personal Injury Protection Act (PIPA) requires that certain information in a claim, including, but not limited to: your personal medical information and any medical or surgical record must be released. This information is to be collected by an insurance company or the State of New York. The State of New York will retain all your personal information. If you desire to make a disability claim using the PIPA, please contact your insurance company or the State of New York to request the information. If your company is not releasing your personal information, you may still need to complete the claim form. Please send any information that you would like to receive on this form with your application. For information on how a disability claim may be processed under the PIPA, please go to . For information about your insurance coverage under the PIPA, please go to . The information in a claim can not be released. The Personal Injury Protection Act (PIPA) requires that certain information in a claim, including, but not limited to: your personal medical information and any medical or surgical record must be released. This information is to be collected by an insurance company or the State of New York. The State of New York will retain all your personal information. If you desire to make a disability claim using the PIPA, please contact your insurance company or the State of New York to request the information. If your company is not releasing your personal information, you may still need to complete the claim form. Please send any information that you would like to receive on this form with your application.

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