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Group Insurance Administration Manual
Group Insurance Administration Manual 
(updated January 21, 2010)
930K - replaced by form M6797(ER330780) below
1285 - replaced by form M4437 below
1541 - replaced by form M6809 below
CSSB.8001 - Life Insurance and Dependents Insurance Appointment and Election Statement
CSSB.8002A - Application for Coverage in the Dependents Insurance Plan
CSSB.8002B - Application for Changes to the Dependents Insurance Plan
(updated June 22/09)
CSSB.8003 - Application for Changes In LIfe Insurance Class
CSSB.8006 - Life Insurance Retirement Notice - requires Adobe Reader 9
(updated Jan.13/09)
CSSB.8007 - Bi-Weekly Premium Remittance Report
CSSB.8008 - Group Insurance Waiver of Premium
CSSB.8009 - Group Life Insurance Death Claim
CSSB.8010 - Dependents Insurance Death Claim
CSSB.8011 - Accidental Disablement Claim
CSSB.8012 - Request for Dependents Insurance or an Increased Number of Units
CSSB.8013 - Request for a Higher Life Insurance Class
CSSB.8014 - Registration Certificate for Insurance Only Members
CSSB.8015 - Termination Notice for Insurance Only Members
CSSB.8016 - Retirement Notice for Insurance Only Members
M4437 - Application for Accidental Disablement or Specific Loss - Employer/Policyholder Statement
M62 (previously 254) - Death Claim Report - Group Life/Dependents/Accidental Death
M6621 [previously G220136H] - Statement of Health for Group Insurance
M6622 [previously G0056ADCE] - Application for Dependents Coverage
M6697 [previously 1536] - Beneficiary Designation
M6723 [previously 1537] - Change in Name Form
M6797(EE330780) (previously 930K) - Waiver of Premium Benefit Application -
Employee's Statement
M6797(ER330780) (previously 930K) - Waiver of Premium Benefit Application -
Employer's Statement
M6809 (previously 1541) - Assignment
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