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