You will need the Adobe Acrobat Reader to view and print these documents. Application for Accelerated Benefits - 95091 Attending Physician's Statement - Proof of Total Disability - 95086 Dismemberment Claim Form - 95048 Group Life Insurance Claim Form - 10831 Dental Claim Form - 95045 LTD Claim - LC-4571-16 LTD Authorization to Obtain and Release Information - LC-5777-9 PHI Authorization for Third Party STD Claim Form Waiver of Premium/Attending Physician's Statement with Application - 95096 Other Dental Coverage Questionnaire - 95054 Group Insurance Self Billed Premium Report