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.

All fields marked with * are required.

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.

If you have any questions, call Client Services at (800) 748-9493, between – CST.

Notice of group disability claim form
Employee's information

Employee's information

Notification Completed by

Notification Completed by:

Correspondence should be sent to:

Correspondence should be sent to:

(If left blank, correspondence will be sent to Insured at address in fields above.)