Group Insurance Administration Manual

Group Insurance Administration Manual (updated October 6, 2011)

Record of Changes To Group Life Administration Manual (updated October 12, 2011)

Forms

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
(last updated June 22/09)

CSSB.8003 - Application for Changes In LIfe Insurance Class

CSSB.8004 - Election to Continue Group Insurance During An Employer Approved Leave of Absence or Lay-Off
(last updated Sept. 20/10)

CSSB.8005 - Election to Waive Group Insurance During An Employer Approved Leave of Absence or Lay-Off

CSSB.8006 - Life Insurance Retirement Notice - requires Adobe Reader 9
(last updated Sept. 10/10)

CSSB.8007 - Bi-Weekly Premium Remittance Report
(last updated Sept. 20/10)

CSSB.8008 - Group Insurance Waiver of Premium Memo
(last updated Sept. 10/10)

CSSB.8009 - Group Life Insurance Death Claim
(last updated Sept. 10/10)

CSSB.8010 - Dependents Insurance Death Claim
(last updated Sept. 10/10)

CSSB.8011 - Accidental Disablement Claim
(last updated Sept. 10/10)

CSSB.8012 - Request for Dependents Insurance or an Increased Number of Units
(last updated December 2011)

CSSB.8013 - Request for a Higher Life Insurance Class
(last updated December 2011)

CSSB.8014 - Registration Certificate for Insurance Only Members
- use for employees not in CSSB pension plan

CSSB.8015 - Termination Notice for Insurance Only Members
- use for employees not in CSSB pension plan

CSSB.8016 - Retirement Notice for Members With Insurance Only (Not in Pension Plan) (last updated Sept. 10/10)

M4437 - Application for Accidental Disablement or Specific Loss - Employer/Policyholder Statement

M5995(330780) [previously M6621 and G220136H] - Group Insurance Medical Questionnaire

M5995(330785) [previously M6622 and G0056ADCE] - Dependents Insurance Medical Questionnaire

M62 (previously 254) - Death Claim Report - Group Life/Dependents/Accidental Death

M6697 [previously 1536] - Beneficiary Designation

M6723 [previously 1537] - Change in Name Form

M6797(AP330780) (previously 930K) - Waiver of Premium Benefit Application -
Attending Physician's Initial Statement

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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