Assurant Employee Benefits

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Form download and instructions

The Forms Index below allows you to quickly download and print commonly used forms. The forms with a Fillable Form icon provide fillable fields that you can complete online. To find more information and instructions about a particular form, click on the 'View instructions' link provided.

Administrative forms | Claim forms | HIPAA forms | Educator Benefits Solutions® forms | Miscellaneous forms

Administrative forms

PDF Format Our forms are available in Portable Document Format (PDF). To view the forms, you may need to download the latest version of Adobe® Acrobat® Reader available at www.adobe.com.

Applications

Employee Application Fillable Form

 

Arkansas | California | Colorado | District of Columbia | Florida | Kansas | Kentucky | Louisiana | Maryland | New Hampshire | New Jersey | New York | North Dakota | Oregon | Pennsylvania | Rhode Island | Virginia | All Other States

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Employee Application (Voluntary Life)

Arizona | California | Connecticut | Florida | Indiana | Kansas | Maryland | Michigan | Minnesota | Montana | New Hampshire | New Jersey (For cases effective prior to 1/1/2005.) | New Jersey (For cases effective on or after 1/1/2005.) | New Mexico | New York | North Dakota | Pennsylvania | South Dakota | Virginia | Wisconsin | All Other States

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Employee Application (Voluntary LTD)

 

Kansas | Maryland | North Dakota | New Hampshire | New Jersey | New York | Pennsylvania | All Other States

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Employee Application For Conversion Coverage Long-term Disability Insurance

 

Kansas | Maryland | New York | All Other States

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Employee Dental Application Fillable Form
For Voluntary or Prepaid Dental Applications call 800.456.9194

Arkansas | California | Colorado | District of Columbia | Florida | Kansas | Louisiana | Maryland | New Hampshire | New Jersey | New York | North Dakota | Oregon | Pennsylvania | Rhode Island | Virginia | All Other States

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Extended Employee Application Fillable Form

 

Arizona | Arkansas | California | Colorado | Connecticut | District of Columbia | Florida | Indiana | Kansas | Kentucky | Louisiana | Maryland | Michigan | Minnesota | Montana | New Hampshire | New Jersey | New York | New Mexico | North Dakota | Oregon | Pennsylvania | Rhode Island | South Dakota | Virginia | Wisconsin | All Other States

View instructions

Application for Continued Employee Life Insurance Fillable Form

 

Minnesota

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Administrative forms – Dental

Request to Elect Dental COBRA Fillable Form

 

New York | All Other States

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Employee Election Form - California COBRA

 

California

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Employer Notice of Qualifying Event - California COBRA

 

California

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Notice to Employees/Dependents Affected by Federal Continuance Law

 

New York

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Notice of COBRA and ERISA Instructions

 

New York

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Administrative forms – Insured Vision

Employee Application

 

Arkansas | California | Kansas | Louisiana | Missouri | New Jersey | New York | New York High/low | Pennsylvania | Rhode Island |Wisconsin | All Other States

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Request to Elect Vision COBRA Fillable Form

 

All States

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Administrative forms – Life

Beneficiary Designation Fillable Form

 

New York | All Other States

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Beneficiary Tips

 

New York | All Other States

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Notice of Conversion Privilege Fillable Form

 

California | Colorado | Connecticut | Florida | Iowa | Kentucky | Louisiana | Michigan | Minnesota | Mississippi | New Hampshire | New York | North Carolina | North Dakota | Oregon | Rhode Island | South Dakota | Texas | Utah | Virginia | Washington | Wisconsin | All Other States

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Specifics of the Minnesota Life Continuation Privilege

 

For MN Employers | For Non-MN Employers

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Notice of Portability Privilege

 

New York | All Other States

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Portability or Application for LTD Conversion – call 866.909.6065

 


Administrative forms – Disability

Facts About Your Conversion Privilege

 

New York | All Other States

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Administrative forms – Other

Portability Employee Application for Accident, Cancer or Critical Illness – call 866.909.6065  

 

Employee Health Statement for Voluntary and Worksite Coverage

 

All Other States | Arkansas | Colorado | Connecticut | District of Columbia| Florida | Illinois | Indiana | Kansas | Kentucky | Louisiana| Maryland | Michigan | Missouri | New Jersey | New Mexico | North Carolina | Pennsylvania | Rhode Island | South Carolina | South Dakota | Utah | Virginia | West Virginia

Faxable Change Document Fillable Form

 

All States

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HIV Testing Consent Forms

 

Arizona | Connecticut | District of Columbia | Georgia | Iowa | Kentucky | Maine | Massachusetts | Missouri | New Hampshire | North Dakota | Ohio | Oregon | Texas | Utah | Vermont | West Virginia

View instructions

Policyholder Eligibility and Participation Statement Fillable Form

 

New York | All Other States

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Requisition for Administration Supplies Fillable Form

 

All States

View instructions

Request to Elect Critical Illness COBRA (AS) Fillable Form

 

All States

Request to Elect Cancer COBRA (AS) Fillable Form

 

All States

Request to Elect Group Hospital Indemnity GAP COBRA(AS) Fillable Form

 

All States

Statement of Loss of Dental Coverage Due to Life Event

 

New York | All Other States | Self-Admin/Funded

View instructions

Voluntary/Worksite Benefits Service Request (AS) Fillable Form

 

All States

Claims forms

PDF Format Our forms are available in Portable Document Format (PDF). To view the forms, you may need to download the latest version of Adobe® Acrobat® Reader available at www.adobe.com.

Dental

Dental Claim Statement Fillable Form

 

New York | All Other States

All Other States (Prepaid)

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Life and AD&D

Life Insurance Claim Statement Fillable Form

 

New York | New Jersey | All Other States

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Accelerated Benefit Claim Statement–Insured/Spouse

 

New York | All Other States

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Accidental Dismemberment Claim Statement

 

New York | All Other States

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ProviderFund

 

All States

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ProviderFund Supplemental Agreement

 

All States

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Surviving Family Claim Statement Fillable Form

 

New York | All Other States

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Disability Claim Statement-Life Insurance Fillable Form

 

New York | All Other States

View instructions


Disability

Short-term Disability Claim Statement Fillable Form

 

New York | All Other States

Spanish ( Español - Declaración Referente a la Reclamación por Concepto de Incapacidad a Corto Plazo)

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Long-term Disability Claim Statement Fillable Form

 

New York | All Other States

Spanish (Español - Declaración Referente a la Reclamación por Concepto de Incapacidad a Largo Plazo)

View instructions

Long-term Disability Claim Statement - Conversion

 

New York | All Other States

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Supplementary Report for Benefits

 

New York | All Other States

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New York State Disability Claim Form Fillable Form

 

New York

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Job Description and Requirements

 

All States

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Addendum to Long-term Disability Claim Statement

 

New York | All Other States

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Job Search Log Sheet Fillable Form

 

All States

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Accident

Accident Claim Statement

 

All States

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Employee Paid Supplement Claim

 

All States

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Wellness Screening Claim Statement

 

All States


Cancer

Cancer Claim Statement

 

All States

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Employee Paid Supplemental Claim

 

All States

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Cancer Screening Claim Statement

 

All States


Critical Illness

Critical Illness Claim Statement

 

All States

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Employee Paid Supplement Claim

All States

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Wellness Screening Claim Statement

 

All States


Hospital Confinement Indemnity “Gap”

Hospital Confinement Indemnity “Gap” Claim Statement

 

All States

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Hospital Confinement Indemnity “Gap” Claim Statement - Spanish

 

All States - Spanish

HIPAA forms

PDF Format Our forms are available in Portable Document Format (PDF). To view the forms, you may need to download the latest version of Adobe® Acrobat® Reader available at www.adobe.com.


Disability-HIPAA Authorization For Release of Health Information

 

California | All Other States

HIPAA Authorization For Release of Protected Health Information

 

All States

HIPAA Authorization For Release of Protected Health Information

 

California

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

 

All States

Medical Underwriting—HIPAA Authorization for Release of Protected Health Information

 

All States

Request for Accounting of Disclosures of Protected Health Information

 

All States

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

 

All States

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

 

All States

Request to Access, Inspect or Copy Protected Health Information

 

All States

Request to Amend or Correct Protected Health Information

 

All States

Educator Benefits Solutions® forms

PDF Format Our forms are available in Portable Document Format (PDF). To view the forms, you may need to download the latest version of Adobe® Acrobat® Reader available at www.adobe.com.

Employer Master Application

 

All States

View instructions

New Business Transmittal

All States

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Employee Application Fillable Form

All States

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Portability Application Fillable Form

All States

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Disability Claim Form

California | All Other States

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Marketing Materials Request Fillable Form

All States

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Miscellaneous forms

PDF Format Our forms are available in Portable Document Format (PDF). To view the forms, you may need to download the latest version of Adobe® Acrobat® Reader available at www.adobe.com.


Appointment of Administrator and Hold Harmless Agreement Fillable Form

New York | All Other States

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Appointment of Administrator and Hold Harmless Agreement - Online Advantage Fillable Form

 

New York | All Other States

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Field Underwriting Assurance Fillable Form

All States

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Group Insurance Preliminary Application Fillable Form

Florida | Kentucky | Maryland | Missouri | New Hampshire (Life, Short-Term Disability, Long-Term Disability, Cancer, Critical Illness, Accident) | New Hampshire (Dental, Vision) | New Jersey | New York | North Carolina | Utah | Virginia | All Other States

View instructions

Third Party Administrator's Statement

All States

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Third Party Administrator's Statement- Maine

Life Conversion | Group Policies