Group Insurance Forms
Member Information Change Form
8001 Group Life and Dependents Insurance Appointment and Election Statement
8002A Application for Coverage in the Dependents Insurance Plan
8002B Application for Changes to the Dependents Insurance Plan
8003 Application for Changes in Life Insurance Class
8004 Election to Continue Group Insurance During An Employer Approved Leave of Absence or Lay Off
8005 Election to Waive Group Insurance During An Employer Approved Leave of Absence or Lay Off
8006 Life Insurance Retirement Notice
8007 Bi-Weekly Premium Remittance Report
8008 Group Insurance Waiver of Premium
8009 Group Life Insurance Death Claim
8010 Dependents Insurance Death Claim
8011 Accidental Disablement Claim
8012 Request for Dependents Insurance or An Increased Number of Units
8013 Request for a Higher Life Insurance Class
8014 Registration Certificate for Insurance Only Members
8015 Termination Notice for Insurance Only Members
8016 Retirement Notice for Insurance Only Members
M4437 Application for Accidental Disablement or Specific Loss - Employer/Policyholder Statement
M5995(330780) Group Life Insurance Medical Questionnaire
M5995(330785) Dependent Insurance Medical Questionnaire
M62 Group Life/Accidental Death & Disablement/Dependents Death Claim Report
M6797(EE330780) Group Life Insurance Waiver of Premium Benefit Application - Employee’s Statement
M6797(ER330780) Group Life Insurance Waiver of Premium Benefit Application - Employer’s Statement