Life Insurance Claim Form

For the beneficiaries of deceased NYU employees to claim life insurance benefits.

NYU provides basic group life insurance for its employees. In addition, some employees have purchased supplemental life insurance through payroll deduction. All employees are requested to designate beneficiaries for their NYU group life insurance. When an employee dies, their beneficiary may file an application for the group life insurance benefits.

Instructions

Beneficiaries of deceased NYU employees may file an application for group life insurance benefits. The completed form should be returned to the NYU Benefits Office along with an official copy of the certificate of death. If an official copy of the certificate of death is not available, have the attending physician complete the reverse side of the form. For more information:

• Code 100, 102, 103, click here.
• Code 104, 106, 107, click here.
• Code 107 PRG, click here.
• Code 107 810, click here.
• Sergeant Guards, click here.