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
No
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?
Yes
No
* 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.)
Address
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.