Enrollment or Termination Form - Employer Paid STD and LTD

For enrollment or termination from Zurich Employer Paid Short-Term and Long-Term Disability

4

Enrollment or Termination Form - Employee Paid STD and LTD

For enrollment or termination from Zurich Employee Paid Short-Term and Long-Term Disability

4

Short-Term and Long-Term Disability Selection Form

Selecting coverage options for employer groups electing to offer short-term and/or long-term disability

2

Evidence of Insurability (EOI) Form

To enroll in certain long-term or short-term disability plans more than 31 days after starting your job

Send completed form to myzurichadmin@zurichna.com, fax to (800) 206-4063, or mail to Zurich Medical Underwriting, PO Box 1685, Grand Rapids, MI 49501-1685