Follow the steps to accurately complete your waiver of premium claim form.

1. Click the ‘Get Form’ button to access the NY Dearborn National Z6293A form and open it in your preferred online editor.
2. Part 1: Employer/Administrator section. Fill out the employer's information, including the group name, subsidiary name, group number, address, authorized representative's details, and contact information. Ensure that this section is completed accurately.
3. Provide the insured person's information including their name, social security number, date of birth, and address. Fill in details about their hire date, insurance effective date, occupation, annual salary, last day worked, and reason for cessation of work.
4. Indicate the date of disability and, if applicable, provide proof of the insured person's death within one year of becoming totally disabled.
5. Part 2: Complete the section for the insured or their legal representative. Input the claimant’s full name (first, last, and middle), social security number, contact information, and details regarding their disability including dates and circumstances.
6. List the employer's name, last day worked, and occupation of the insured individual. Include the details of treating physician(s) and any hospitals where treatment was received.
7. Part 3: The attending physician must complete this section, detailing the patient’s information, diagnosis, treatment, and the level of disability. Ensure the physician provides their signature and date.
8. Review all provided information for accuracy and completeness. Make sure that the agreements and authorization for the release of information are signed appropriately.
9. Once all sections are completed, save your changes, download the form, print it, or share it as needed for submission to the Dearborn National claims department.

Start filling out your NY Dearborn National Z6293A form online today for a seamless claims process.