Dismemberment benefit

Covered injuries:

• Loss of your hand by actual severance through or above the wrist.
• Loss of your foot by actual severance through or above the ankle joint.
• Loss of your sight in one eye resulting in total and permanent loss of vision that cannot be recovered by surgery or other means.

If you are in an accident and suffer one of the covered injuries: 

Dismemberment Benefit Claims Form available on the Minnesota Life website.

Part 1 - Should be completed by the employer.

Part 2 - Should be completed by the claimant or authorized representative. If guardianship or power of attorney has been executed, please attach certified copies of the official designation.

Part 3 - Should be completed by your physician. Please note, we are requesting that copies of your medical records be submitted with this form by your physician to assist in expediting our review.

Please print or type answers clearly, and answer all questions as completely as possible. Unanswered questions could result in additional requests for information and require additional time in processing your claim.

Once completed, the form needs to be returned to Minnesota Life at the address on the form.