Downloadable Forms

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• Life, Disability, Vision and Supplemental Health 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.
• Evidence of Insurability - Spanish — Medical Evidence of Insurability for coverage changes.
• Portability Application – Life — Use to continue Life coverage due to termination.
• Portability Application – Accident — Use to continue Accident coverage due to termination.
• Portability Application – Hospital Indemnity — Use to continue Hospital Indemnity coverage due to termination.
• Portability Application – Critical Illness — Use to continue Critical Illness coverage due to termination.
• Portability Application – Spanish — Use to continue Life coverage due to termination.
• 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.
• Beneficiary Designation — Use for designating beneficiaries for life and disability benefits.
• Beneficiary Designation - Spanish — Use for designating beneficiaries for life and disability benefits.
• 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 — This form is to be completed by the employer.
• Broker Authorization for Group Changes — Employers can authorize the broker of record to complete group changes on their behalf.
• Policyholder Vendor Authorization/Change Form — When an eligibility or medical integration file is established with a Policyholder’s Vendor, this authorization form must be completed.