Administrative form instructions

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Employee Application

This employee form is used when applying for coverage under their employer's Assurant Employee Benefits group insurance policy. The employer should have the employee complete this form and then fax to 888.208.2323.

Employee Application (Voluntary Life)

This employee form is used when applying for coverage under their employer's Assurant Employee Benefits voluntary life policy. The employer should have the employee complete this form and then fax to 888.208.2323.

Employee Application (Voluntary LTD)

This employee form is used when applying for coverage under their employer's Assurant Employee Benefits voluntary LTD policy. The employer should have the employee complete this form and then fax to 888.208.2323.

Employee Application For Conversion Coverage Long-term Disability Insurance

This employee form is used when requesting conversion of your long-term disability policy.

Employee Dental Application

This employee form is used when dental is the only coverage the employer has with Assurant Employee Benefits. Please have the employee complete this form. Select the applicant's state of residence from the list above and an Employee Dental Application will appear.

Extended Employee Application

This employee form is used if you should need to provide proof of health. All health questions must be answered and complete details provided to any yes answers. Please select the applicant's state of residence from the list and an Extended Employee Application will appear.

Application for Continued Employee Life Insurance (Minnesota)

This employee form is used for any person living/working in the state of Minnesota and is eligible to continue their life insurance if employment was terminated or they no longer meet the eligibility requirements. A dependent would be eligible due to divorce, death or termination of the employee.

Request to Elect Dental COBRA

This employee form is an election form and should be completed as follows when a qualifying event has occurred, to establish continuation of dental coverage under the employer's group insurance plan, or to waive the right to continue the coverage.

  • Employer Section - to be completed by the employer
  • Qualified Individual Section - to be completed by the employee

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

This employee form is an election form and should be completed as follows when a qualifying event has occurred, to establish continuation of dental coverage under the employer's group insurance plan, or to waive the right to continue the coverage, as stipulated by the Cal-COBRA law:

  • Employer Section - to be completed by the employer
  • Qualified Individual Section - to be completed by the employee

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

This employer form is a notice informing you of your responsibilities in aiding California employees to obtain an extension of dental coverage, when a qualifying event occurs, as stipulated by the Cal-COBRA law.

Employee Application

This employee form is used when applying for coverage under their employer's Assurant Employee Benefits group insurance policy.

Request to Elect Vision COBRA

This employee form is an election form and should be completed as follows when a qualifying event has occurred, to establish continuation of vision coverage under the employer's group insurance plan, or to waive the right to continue the coverage.

  • Employer Section - to be completed by the employer
  • Qualified Individual Section - to be completed by the employee

Notice to Employees/Dependents Affected by Federal Continuance Law (For use in New York)

This employee form is an election form and should be completed as follows when a qualifying event has occurred, to establish continuation of dental coverage under the employer's group insurance plan, or to waive the right to continue the coverage, as stipulated by the New York law.

Notice of COBRA and ERISA Instructions (For use in New York)

This employer form is a notice informing you of your responsibilities in aiding New York employees to obtain an extension of dental coverage, when a qualifying event occurs, as stipulated by the law.

Beneficiary Designation

This employee form is used when an applicant wishes to name or change his/her beneficiary. Please complete all requested information and sign and date the form.

Beneficiary Tips

This employee form is used to learn more about selecting a beneficiary.

Notice of Conversion Privilege

This employee form is used to convert your basic group life coverage to an individual life insurance policy. This form advises the employee how to obtain a quote and an application.

Specifics of the Minnesota Life Continuation Privilege (for MN Employers)

This is a form that should be included as part of the COBRA packet. If a Minnesota employee terminates employment, they can continue their life insurance benefit (only) up to 18 months.

Notice of Portability Privilege

This employee form is used to Port your Voluntary group life coverage to an individual life insurance policy. This form advises the employee how to obtain a quote and an application.

Specifics of the Minnesota Life Continuation Privilege (for Non-MN Employers)

This is a form that should be included as part of the COBRA packet. If a Minnesota employee terminates employment, they can continue their life insurance benefit (only) up to 18 months.

Facts About Your Conversion Privilege

This employee form is used to learn more about converting your long-term disability policy.

Faxable Change Document

This employer form is used for reporting terminations, salary changes, employee name changes, and adding/deleting coverage(s) on an employee level. Please provide the certificate number, employee name, effective date of the change being reported and any applicable information. This form is not to be used for enrollments. Please complete an Employee Application in order to add an applicant to your group policy.

Please do not fax any changes which you have already reported or mail any changes that you have previously faxed.

HIV Testing Consent Forms

  • When you have an applicant who needs blood and/or urine testing, please have the individual complete this form.
  • Please select the applicant's state of residence from the list, if applicable, and an HIV Testing Consent Form will be displayed.
  • Print this consent form and have it completed and signed by the applicant. After it is completed, you should include it in the laboratory kit.

Notice of Accident Only Portability Privilege

This employee form is used to Port your group accident coverage to an individual accident insurance policy. This form advises the employee how to obtain a quote and an application.

Notice of Cancer Only Portability Privilege

This employee form is used to Port your group cancer coverage to an individual cancer insurance policy. This form advises the employee how to obtain a quote and an application.

Notice of Critical Illness Portability Privilege

This employee form is used to Port your group critical Illness coverage to an individual critical Illness insurance policy. This form advises the employee how to obtain a quote and an application.

Policyholder Eligibility and Participation Statement

This employer form is used to verify participation within the group and to capture the percentage of premium that the employer contributes. The form is used for both contributory and voluntary coverage.

Requisition for Administration Supplies

This employer form is used for requesting administrative supplies such as enrollment cards, claim forms, or certificate booklets.

Statement of Loss of Dental Coverage Due to Life Event

This employer form is used when requesting to waive the Late Entrant Limitation for a specific employee. Along with this statement, proof of prior coverage will need to be included when submitting.

Statement of Loss of Dental Coverage Due to Life Event (Self-Admin/Funded)

This employer form is used when requesting to waive the Late Entrant Limitation for a specific employee. Along with this statement, proof of prior coverage will need to be included when submitting.

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