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

 

M6697 Beneficiary Designation

 

M6797(AP330780) Group Life Insurance Waiver of Premium Benefit Application - Attending Physician’s Initial Statement

 

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

 

M6809 Assignment