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To report a claim or request a benefit activation, select the form that best describes your situation.
Follow the instructions and complete the required fields to ensure timely processing.
If you need assistance in identifying the correct form or assistance in completing a form, please call the Pekin Insurance Financial Products Benefits Center at 1-800-322-1060, Extension 2521.

Death Claim – Required Forms
LK 14 – Death Claim Form
LK 210 – Scriptcheck Authorization
LK 209 – Statement of Authority

HIPAA Authorization (Choose Your State)
LU 129MN – Minnesota
LU 129OH – Ohio
LU 129VA – Virginia
LU 129WI – Wisconsin
LU 129 – All other states not listed above

Disability Claim – Required Forms

LK15-16 – Disability Claim Form

HIPAA Authorization (Choose Your State)
LU 129MN – Minnesota
LU 129OH – Ohio
LU 129VA – Virginia
LU 129WI – Wisconsin
LU 129 – All other states not listed above

Call Toll-Free 1-800-322-0160