Applications

Employee Application

Employee Application (Voluntary Life)

Employee Application (Voluntary LTD)

Employee Application For Conversion Coverage Long-term Disability Insurance

Employee Dental Application
For Voluntary or Prepaid Dental Applications call 800.456.9194

Extended Employee Application

Application for Continued Employee Life Insurance

Administrative forms – Dental

Request to Elect Dental COBRA

Request to Elect COBRA-California (Cal-COBRA, For Groups Under 20 Lives)

Notice of COBRA and ERISA Instructions

Important Notice to Employers affected by California Continuation of Benefits Replacement Act (Cal-COBRA, For Groups Under 20 Lives)

Administrative forms – Insured Vision

Employee Application

Request to Elect Vision COBRA

Administrative forms – Life

Beneficiary Designation

Beneficiary Tips

Notice of Conversion Privilege

Specifics of the Minnesota Life Continuation Privilege

Notice of Portability Privilege

Portability or Application for LTD Conversion – call 866.909.6065

Administrative forms – Disability

Facts About Your Conversion Privilege

Administrative forms – Other

Faxable Change Document

HIV Testing Consent Forms

Policyholder Eligibility and Participation Statement

Requisition for Administration Supplies

Statement of Loss of Dental Coverage Due to Life Event

Dental

Dental Claim Statement

Life and AD&D

Life Insurance Claim Statement

Accelerated Benefit Claim Statement–Insured/Spouse

Accidental Dismemberment Claim Statement

ProviderFund

Surviving Family Claim Statement

Disability Claim Statement-Life Insurance

Disability

Short-term Disability Claim Statement

Long-term Disability Claim Statement

Long-term Disability Claim Statement - Conversion

Supplementary Report for Benefits

New York State Disability Claim Form

Job Description and Requirements

Addendum to Long-term Disability Claim Statement

Job Search Log Sheet

Accident

Accident Claim Statement

Employee Paid Supplemental Claim

Cancer

Cancer Claim Statement

Employee Paid Supplemental Claim

Critical Illness

Critical Illness Claim Statement

Employee Paid Supplemental Claim

Hospital Confinement Indemnity “Gap”

Hospital Confinement Indemnity “Gap” Claim Statement

Supplemental Hospital Confinement Indemnity "Gap" Claim Form

Disability-HIPAA Authorization For Release of Health Information

HIPAA Authorization For Release of Protected Health Information

HIPAA Authorization For Release of Protected Health Information

Instructions and Helpful Hints for Completing the HIPAA Authorization for Release of Protected Health Information

Medical Underwriting—HIPAA Authorization for Release of Protected Health Information

Request for Accounting of Disclosures of Protected Health Information

Request for Confidential and/or Alternative Communications of Protected Health Information

Request for Restrictions on the Use and Disclosure of Protected Health Information

Request to Access, Inspect or Copy Protected Health Information

Request to Amend or Correct Protected Health Information

Employer Master Application

New Business Transmittal

Employee Application

Portability Application

Disability Claim Form

Marketing Materials Request

Appointment of Administrator and Hold Harmless Agreement

Appointment of Administrator and Hold Harmless Agreement - Online Advantage

Field Underwriting Assurance

Group Insurance Preliminary Application

Third Party Administrator's Statement