Downloadable Forms

Download the forms you need to efficiently administer your ancillary products.

Life, Disability, Accident, Critical Illness, Vision and Dental Enrollment and Change Form  – You may use this form to enroll in any or all of our group ancillary products.

Evidence of Insurability  – Medical Evidence of Insurability for coverage changes.

Portability Application – Life  – Use to continue Life coverage due to terminate.

Portability Application – Accident  – Use to continue Accident coverage due to terminate.

Portability Application – Critical Illness  – Use to continue Critical Illness coverage due to terminate.

Application to Convert Group Life Insurance  – Conversion allows Employees and their covered dependents to convert some of their Basic Life and/or Voluntary Life insurance to an individual whole life policy.

Benefits Manager Registration  – Use to register for secure online group administration.

Group Application Packet  – Contains all forms needed to apply for coverage. Must be submitted with the Producer Transmittal form.

Producer Transmittal  – This form is to be completed by the producer regarding coverage. Must be submitted with the Group Application.

Third Party Administrator Questionnaire  – Complete this form if a third party will be administering your plan.

FICA Tax/W2 Agreement  – Must be included with all Disability group applications.

Broker Authorization for Group Changes  – This form is to be completed by the Group for Broker Authorizations or to revoke Broker Authorizations for group changes. Must be submitted with Group Transmittal.

Policyholder Vendor Authorization/Change Form  – This form is to be completed if the Group uses a third-party administrator. Must be submitted with Group Transmittal.

Accidental Death & Dismemberment Claim Form 

Accelerated Death Benefit Claim Form 

Critical Illness Claim Form 

Critical Illness Wellness Benefit Claim Form 

Accident Claim Form 

Life Insurance Claim Form 

Life Insurance Claim Form - Spanish 

Long-Term Disability Claim Form 

Long-Term Disability Claim Form - Spanish 

Short-Term Disability Claim Form 

Short-Term Disability Claim Form - Spanish 

Vision Claim Form 

Waiver of Premium Claim Form 

Long-Term Disability Conversion Kit