Preliminary Notice of Disability - Group DI

To inform Northwestern Mutual of a disability, please complete the following form.

Note: Only one notification is necessary to inform Northwestern Mutual of a disability claim. Upon receipt of the information, a personalized claim kit will be sent to you. This kit contains the forms and instructions you need to complete your claim application.

Employee's Information
All fields marked with * are required
* Name
* Address
* City, State, Zip
Telephone Number
* Birth Date (mm/dd/yyyy) (Approximate, if unknown)
Group Name (Employer) /
Group Number
* Does the Employee have Northwestern Mutual Individual Disability Insurance or Life Insurance with the Waiver of Premium Benefit? Yes
Individual Policy Number

Complete this field if above question answered yes.
* Date of Disability (mm/dd/yyyy) (Approximate, if unknown)
* Cause of Disability

Accident, Sickness, or Both. Please describe.
* Occupation
The Insured is Claiming       Total Disability
      Partial Disability
Notification Completed by
* Name
* Telephone Number
* Has your Northwestern Mutual Financial Network Representative or local office been notified?
* If yes, please provide the date that the Financial Representative was notified (mm/dd/yyyy)
Correspondence should be sent to: (If left blank, correspondence will be sent to Insured at address in fields above.)
City, State, Zip
If you have any questions, call us at (800) 378-4665, between 9:00 a.m. and 7:00 p.m. CST.