Field Referral Form

Field Visit Request Form for Printing and Faxing
Fax to (860)769-6981
Field Visit Request.doc
Microsoft Word document [54.0 KB]


Report a Claim

To start the claims process, we will need the following information:


  • Policyholder information: Name of insured, address, phone number, e-mail and policy number
  • Date of Disability: Date your disability started
  • Employer information: Employer name address and contact information if your policy is through your employer


Please send your claims information to:


Disability Insurance Specialists, LLC

PO Box 25

Bloomfield, CT 06002


Fax: 860 243-6562



To go to our secure file transfer portal click this link: