q First Commonwealth of Missouri, Inc.

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "q First Commonwealth of Missouri, Inc."

Transcription

1 The Guardian Life Insurance Company of America q The Guardian Life Insurance company of America underwrites group term ife, accidenta death and dismemberment, short term disabiity, ong term disabiity, critica iness, denta and vision coverages. q First Commonweath of Missouri, Inc. First Commonweath of Missouri, Inc. underwrites group pre-paid denta coverage Enroment/Change Form Page 1 of 8 Guardian Life, P.O. Box 14319, Lexington, KY Pease print ceary and mark carefuy. Empoyer Name: COLUMBIA COLLEGE Group Pan Number: Benefits Effective: PLEASE CHECK APPROPRIATE BOX q Initia Enroment q Re-Enroment q Add Empoyee/Dependents q Drop/Refuse Coverage q Information Change q Increase Amount q Famiy Status Change Cass: ALL OTHER ELIGIBLE EMPLOYEES Division: Subtota Code: (If appicabe, pease obtain this from your Empoyer) About You: First, MI, Last Name: Socia Security Number - - Address City State Zip Gender: q M q F Date of Birth(mm-dd-yy): - - Phone:( ) - Emai Address: Are you married or do you have a spouse? q Yes q No Date of marriage/union: - - Do you have chidren or other dependents? q Yes q No Pacement date of adopted chid: - - About Your Job: Hours worked per week: Job Tite: Work Status: q Active q Retired q Cobra/State Continuation Date of fu time hire: - - Annua Saary: $ About Your Famiy: Pease incude the names of the dependents you wish to enro for coverage. A dependent is a person that you, as a taxpayer, caim; who reies on you for financia support; and for whom you quaify for a dependency tax exception. Dependency tax exemptions are subject to IRS rues and reguations. Additiona information may be required for non-standard dependents such as a grandchid, a niece or a nephew. Spouse (First, MI, Last Name) Phone: ( ) - Chid/Dependent 1: Gender q M q F q Add q Drop Gender q M q F Socia Security Number - - Date of Birth (mm-dd-yyyy) - - Socia Security Number - - Status (check a that appy) q Student (post high schoo) q Disabed q Non standard dependent Phone: ( ) - Chid/Dependent 2: Phone: ( ) - q Add q Drop Gender q M q F Date of Birth (mm-dd-yyyy) - - Socia Security Number - - Date of Birth (mm-dd-yyyy) - - Status (check a that appy) q Student (post high schoo) q Disabed q Non standard dependent CEF2014-MO DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER DATE FORM PUBLISHED: Nov 05,

2 Chid/Dependent 3: q Add q Drop Gender q M q F Socia Security Number - - Status (check a that appy) q Student (post high schoo) q Disabed q Non standard dependent Phone: ( ) - Chid/Dependent 4: Phone: ( ) - q Add q Drop Gender q M q F Date of Birth (mm-dd-yyyy) - - Socia Security Number - - Date of Birth (mm-dd-yyyy) - - Status (check a that appy) q Student (post high schoo) q Disabed q Non standard dependent Drop Coverage: q Drop Empoyee q Drop Dependents The date of withdrawa cannot be prior to the date this form is competed and signed. Last Day of Coverage: - - q Termination of Empoyment q Retirement Last Day Worked: - - q Other Event: Date of Event: - - Loss Of Other Coverage: I and/or my dependents were previousy covered under another insurance pan. Loss of coverage was due to: q Termination of Empoyment: - - q Divorce - - q Death of Spouse - - q Termination/Expiration of Coverage - - Coverage Lost q Denta q Vision Coverage Being Dropped: q Denta q Empoyee q Spouse q Chid(ren) q Vision q Empoyee q Spouse q Chid(ren) q Basic Life q Empoyee q Spouse q Chid(ren) q Vountary Life q Empoyee q Spouse q Chid(ren) q VAD&D q Empoyee q Spouse q Chid(ren) q Critica Iness q Empoyee q Spouse q Chid(ren) q Accident q Empoyee q Spouse q Chid(ren) q Cancer q Empoyee q Spouse q Chid(ren) q Muti-Coverage q Long Term Disabiity q Short Term Disabiity I have been offered the above coverage(s) and wish to drop enroment for the foowing reasons: q Covered under another insurance pan q Other (additiona information may be required) Denta Coverage: You must be enroed to cover your dependents. Check ony one box. Empoyee Ony EE, Spouse & Dependent/Chid(ren) PPO q q q I do not want this coverage. If you do not want this Denta Coverage, pease mark a that appy: q I am covered under another Denta pan q My spouse is covered under another Denta pan q My dependents are covered under another Denta pan Vision Coverage: You must be enroed to cover your dependents. Check ony one box. Your Semi-monthy Premium Empoyee Ony EE & Spouse EE & EE, Spouse & Dependent/Chid(ren) Dependent/Chid(ren) Fu Feature q $6.66 q $10.65 q $10.88 q $17.53 q I do not want this coverage. If you do not want this Vision Coverage, pease mark a that appy: q I am covered under another Vision pan q My spouse is covered under another Vision pan q My dependents are covered under another Vision pan 2 DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER

3 Guardian Group Pan Number: Pease print empoyee name: Basic Life Coverage with Accidenta Death and Dismemberment (AD&D): Benefit reductions appy. Pease see pan administrator. Poicy Amount Empoyee Ony R 200% of your annua saary to a maximum of $250,000 q I do not want this coverage. Name your beneficiaries: (Primary beneficiary percentages must tota 100%) Primary Beneficiaries: Name: Socia Security Number: - - % Date of Birth (mm-dd-yy): - - Phone: ( ) - Reationship to Empoyee:_ Name: Socia Security Number: - - % Date of Birth (mm-dd-yy): - - Phone: ( ) - Reationship to Empoyee:_ Contingent Beneficiary: Socia Security Number: - - Date of Birth (mm-dd-yy): - - Phone: ( ) - Reationship to Empoyee:_ (In the event the primary beneficiaries are deceased, the contingent beneficiary wi receive the benefit. Empoyer maintains beneficiary information.) If this Basic Life poicy wi repace your existing ife insurance poicy under your current empoyer, provide the amount of the previous poicy $ Important Notes: Based on your pan benefits and age, you may be required to compete an evidence of insurabiity form for Basic Life. Vountary Term Life Coverage With Accidenta Death and Dismemberment (AD&D): reductions appy. Pease see pan administrator. Empoyee You must be enroed to cover your dependents. Benefit Poicy Amount Check one box ony q $20,000 q $30,000 q $40,000 q $50,000 q $60,000 q $70,000 q $80,000 q $90,000 q $100,000 q $110,000 q $120,000 q $130,000 q $140,000 q $150,000* q $160,000 q $170,000 q $180,000 q $190,000 q $200,000 q $210,000 q $220,000 q $230,000 q $240,000 q $250,000 q $260,000 q $270,000 q $280,000 q $290,000 q $300,000 q $310,000 q $320,000 q $330,000 q $340,000 q $350,000 q $360,000 q $370,000 q $380,000 q $390,000 q $400,000 q $410,000 q $420,000 q $430,000 q $440,000 q $450,000 q $460,000 q $470,000 q $480,000 q $490,000 q $500,000 *Guarantee Issue Amount q I do not want this coverage Add Vountary Life for Spouse Poicy Amount q $5,000 q $10,000 q $15,000 q $20,000 q $25,000 q $30,000 q $35,000 q $40,000 q $45,000 q $50,000* q $55,000 q $60,000 q $65,000 q $70,000 q $75,000 q $80,000 q $85,000 q $90,000 q $95,000 q $100,000 q $105,000 q $110,000 q $115,000 q $120,000 q $125,000 q $130,000 q $135,000 q $140,000 q $145,000 q $150,000 q $155,000 q $160,000 q $165,000 q $170,000 q $175,000 q $180,000 q $185,000 q $190,000 q $195,000 q $200,000 q $205,000 q $210,000 q $215,000 q $220,000 q $225,000 q $230,000 q $235,000 q $240,000 q $245,000 q $250,000 *Guarantee Issue Amount *The amount may not be more than 0% of the empoyee amount for Vountary Life. q I do not want this coverage 3 DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER

4 LIFE INSURANCE continued Add Vountary Life for Dependent/Chid(ren) Poicy Amount q $1,000 q $5,000 q $10,000* *Guarantee Issue Amount *The amount may not be more than 10% of the empoyee amount for Vountary Life. q I do not want this coverage Have you used any form of tobacco in the past 6 months (e.g., pipe, chewing tobacco) and/or have you smoked cigarettes in the past 12 months? Empoyee Yes q No q Spouse Yes q No q Important Notes: Based on your pan benefits and age, you may be required to compete an evidence of insurabiity form for Vountary Life. Name your beneficiaries: (Primary beneficiary percentages must tota 100%) If eecting different beneficiaries that are not the same as those named for Basic Life, pease name beow. Primary Beneficiaries: Name: Socia Security Number: - - % Date of Birth (mm-dd-yy): - - Phone: ( ) - Reationship to Empoyee:_ Name: Socia Security Number: - - % Date of Birth (mm-dd-yy): - - Phone: ( ) - Reationship to Empoyee:_ Contingent Beneficiary: Date of Birth (mm-dd-yy): - - Phone: ( ) - Reationship to Empoyee:_ Socia Security Number: - - (In the event the primary beneficiaries are deceased, the contingent beneficiary wi receive the benefit. Empoyer maintains beneficiary information.) Short-Term Disabiity (STD) Coverage: Weeky Benefit q $ q $ q $ q $ q $ q $ q $ q $ q $1, q $1, This amount may not exceed 60% of your weeky saary. q I do not want this coverage. Long-Term Disabiity (LTD) Coverage: Weeky Benefit q $1, q $1, q $1, q $1, Monthy Benefit R 60% of saary to a maximum of $7,500 4

5 Guardian Group Pan Number: Pease print empoyee name: Critica Iness Coverage: You must be enroed to cover your dependents Benefit reductions appy. Pease see pan administrator. Empoyee Insurance Amount: q $5,000 q $10,000 q $15,000 q $20,000 q $25,000 q $30,000 q $35,000 q $40,000 q $45,000 q $50,000 q I do not want this coverage. Spouse Insurance Amount: Up to 50% of the empoyee's amount to a maximum of $12,500 q $2,500 q $5,000 q $7,500 q $10,000 q $12,500 q I do not want this coverage. Dependent/Chid(ren) Insurance Amount: q 25% of the empoyee's amount q I do not want this coverage. Have you used any form of tobacco in the past 6 months (e.g. pipe, chewing tobacco) and/or have you smoked cigarettes in the past 12 months? Empoyee q Yes q No Spouse q Yes q No If eecting Critica Iness Coverage, you must answer the foowing heath questions. 1. Has any proposed insured been diagnosed with or treated by a medica professiona for any of the foowing conditions: cancer, carcinoma in situ,maignant meanoma, tumor (benign or maignant), Barretts esophagus, Crohns disease, ucerative coitis, bood disorder (other than AIDS or HIV), any chronic or progressive disease of kidneys, iver (incuding hepatitis), ungs, incuding emphysema and COPD, pancreas or bone marrow? Or, been advised to have an organ transpant, incuding bone marrow or stem ce transpant? Empoyee q Yes q No Spouse q Yes q No 2. Has any proposed insured been diagnosed with or treated by a medica professiona for heart attack, heart disease or coronary artery disease, stroke or transient ischemic attack (TIA), or been advised to have bypass surgery, stent insertions or treatment for coronary arteries? Empoyee q Yes q No Spouse q Yes q No 3. Has any proposed insured been diagnosed with or treated by a medica professiona for uncontroed bood pressure (requiring a change in medication or dosage in the past 6 months or been diagnosed with or treated for diabetes (except if present ony in pregnancy)? Empoyee q Yes q No Spouse q Yes q No 4. Has any proposed insured been diagnosed with or treated by a medica professiona for AIDS (acquired immune deficiency syndrome), AIDS-Reated Compex or tested positive for HIV (human immunodeficiency virus)? Empoyee q Yes q No IMPORTANT NOTES: Spouse q Yes q No Based on your pan benefits and age, you may be required to compete an additiona evidence of insurabiity form for Critica Iness. Accident Coverage You must be enroed to cover your dependents. Your Semi-monthy premium Empoyee Ony EE & Spouse EE & Dependent/Chid(ren) EE, Spouse & Dependent/Chid(ren) q $8.10 q $11.58 q $15.45 q $18.93 q I do not want this coverage. 5 DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER

6 Name your beneficiaries: (Primary beneficiary percentages must tota 100%) Primary Beneficiaries: Name: Socia Security Number: - - % Date of Birth (mm-dd-yy): - - Phone: ( ) - Reationship to Empoyee:_ Name: Socia Security Number: - - % Date of Birth (mm-dd-yy): - - Phone: ( ) - Reationship to Empoyee:_ Contingent Beneficiary: Date of Birth (mm-dd-yy): - - Phone: ( ) - Reationship to Empoyee:_ Socia Security Number: - - (In the event the primary beneficiaries are deceased, the contingent beneficiary wi receive the benefit. Empoyer maintains beneficiary information.) Signature An empoyee's decision to eect Vision or not eect Vision must be retained unti the next pan's Open Enroment period. If the empoyee eects not to enro in vision coverage, they are not eigibe to enro unti the pan's next Open Enroment period. I understand that ife insurance coverage for a dependent, other than a newborn chid, wi not take effect if that dependent is confined to a hospita or other heath care faciity, or is home confined, or is unabe to perform two or more Activities of Daiy Living (ADL's). I understand that my dependent(s) cannot be enroed for a coverage if I am not enroed for that coverage. I understand that the premium amounts shown above are estimations and are for iustrative purposes ony. Submission of this form does not guarantee coverage. Among other things, coverage is contingent upon underwriting approva and meeting the appicabe eigibiity requirements as set forth in the appicabe benefit booket. I understand that I must be activey at work or my eected coverage wi not take effect unti I have met the eigibiity requirements (as defined in the benefit booket.) This does not appy to eigibe retirees. If coverage is waived and you ater decide to enro, ate entrant penaties may appy. You may aso have to provide, at your own expense, proof of each person's insurabiity. Guardian or its designee has the right to reject your request. Pan design imitations and excusions may appy. For compete detais of coverage, pease refer to your benefit booket. State imitations may appy. Your coverage wi not be effective unti approved by a Guardian or its designated underwriter. I hereby appy for the group benefit(s) that I have chosen above. I understand that I must meet eigibiity requirements for a coverages that I have chosen above. I agree that my empoyer may deduct premiums from my pay if they are required for the coverage I have chosen above. I acknowedge and consent to receiving eectronic copies of appicabe insurance reated documents, in ieu of paper copies, to the extent permitted by appicabe aw. I may change this eection ony by providing thirty (30) day prior written notice. I attest that the information provided above is true and correct to the best of my knowedge. Any person who with intent to defraud any insurance company or other person fies an appication for insurance or statements of caim containing any knowingy, fase information, or conceas for purpose of miseading information concerning any fact materia hereto, commits a frauduent insurance act, which is a crime, and may aso be subject to civi penaties, or denia of insurance benefits. The state in which you reside may have a specific state fraud warning. Pease refer to the attached Fraud Warning Statements page. The aws of New York require the foowing statement appear: Any person who knowingy and with intent to defraud any insurance company or other person fies an appication for insurance or statement of caim containing any materiay fase information, or conceas for the purpose of miseading, information concerning any fact materia thereto, commits a frauduent insurance act, which is a crime, and sha aso be subject to a civi penaty not to exceed five thousand doars and the stated vaue of the caim for each such vioation. (Does not appy to Life Insurance.) SIGNATURE OF EMPLOYEE X DATE Enroment Kit , 0001, EN 6

7 Guardian Group Pan Number: Pease print empoyee name: Fraud Warning Statements The aws of severa states require the foowing statements to appear on the enroment form: Aabama: Any person who knowingy presents a fase or frauduent caim for payment of a oss or benefit or who knowingy presents fase information in an appication for insurance is guity of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. Arizona: For your protection Arizona aw requires the foowing statement to appear on this form. Any person who knowingy presents a fase or frauduent caim for payment of a oss is subject to crimina and civi penaties. Caifornia: For your protection Caifornia aw requires the foowing to appear on this form: Any person who knowingy presents fase or frauduent caim for the payment of a oss is guity of a crime and may be subject to fines and confinement in state prison. Coorado: It is unawfu to knowingy provide fase, incompete, or miseading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penaties may incude imprisonment, fines, denia of insurance, and civi damages. Any insurance company or agent of an insurance company who knowingy provides fase, incompete, or miseading facts or information to a poicy hoder or caimant for the purpose of defrauding or attempting to defraud the poicy hoder or caimant with regard to a settement or award payabe from insurance proceeds sha be reported to the Coorado Division of Insurance within the Department of Reguatory Agencies. Connecticut, Iowa, Kansas, Nebraska, Oregon, and Vermont: Any person who knowingy, and with intent to defraud any insurance company or other person, fies an appication of insurance or statement of caim containing any materiay fase information or conceas, for the purpose of miseading, information concerning any fact materia thereto, may be guity of a frauduent insurance act, which may be a crime, and may aso be subject to civi penaties. Deaware, Indiana and Okahoma: WARNING: Any person who knowingy, and with intent to injure, defraud or deceive any insurer, makes any caim for the proceeds of an insurance poicy containing any fase, incompete or miseading information is guity of a feony. District of Coumbia: WARNING: It is a crime to provide fase or miseading information to an insurer for the purpose of defrauding the insurer or any other person. Penaties incude imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if fase information materiay reated to a caim was provided by the appicant. Forida: Any person who knowingy and with intent to injure, defraud, or deceive any insurer fies a statement of caim or an appication containing any fase, incompete, or miseading information is guity of a feony of the third degree. Kentucky: Any person who knowingy and with intent to defraud any insurance company or other person fies a statement of caim containing any materiay fase information or conceas, for the purpose of miseading, information concerning any fact materia thereto commits a frauduent insurance act, which is a crime. Louisiana and Texas: Any person who knowingy presents a fase or frauduent caim for payment of a oss or benefit is guity of a crime and may be subject to fines and confinements in state prison. Maine, Tennessee, Virginia and Washington: It is a crime to knowingy provide fase, incompete or miseading information to an insurance company for the purpose of defrauding the company. Penaties may incude imprisonment, fines or a denia of insurance benefits. Maryand and Rhode Isand: Any person who knowingy and wifuy presents a fase or frauduent caim for payment of a oss or benefit or knowingy and wifuy presents fase information in an appication for insurance is guity of a crime and may be subject to fines and confinement in prison. Minnesota: A person who fies a caim with intent to defraud or heps commit a fraud against an insurer is guity of a crime. New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, fies a statement of caim containing any fase, incompete or miseading information is subject to prosecution and punishment for insurance fraud, as provided in N.H. Rev. Stat. Ann. 638:20 New Jersey: Any person who knowingy fies a statement of caim containing any fase or miseading information is subject to crimina and civi penaties. New Mexico: Any person who knowingy presents a fase or frauduent caim for payment or a oss or benefit or knowingy presents fase information in an appication for insurance is guity of a crime and may be subject to civi fines and crimina penaties or denia of insurance benefits. Ohio: Any person who with intent to defraud or knowing that he/she is faciitating a fraud against an insurer, submits an appication or fies a caim containing a fase or deceptive statement is guity of insurance fraud. Pennsyvania: Any person who knowingy and with intent to defraud any insurance company or other person fies an appication for insurance or statement of caim containing any materiay fase information or conceas for the purpose of miseading, information concerning any fact materia thereto commits a frauduent insurance act, which is a crime and subjects such person to crimina and civi penaties. 7 DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER

8 8

9 39

10 40

11 41

12 42

13 43

14 44

Welcome to Colonial Voluntary Benefits. Thank you for your interest in our Universal Life with the Accelerated Death Benefit for Long Term Care Rider.

Welcome to Colonial Voluntary Benefits. Thank you for your interest in our Universal Life with the Accelerated Death Benefit for Long Term Care Rider. Heo, Wecome to Coonia Vountary Benefits. Thank you for your interest in our Universa Life with the Acceerated Death Benefit for Long Term Care Rider. For detai pease ca 877-685-2656. Pease eave your name,

More information

Group Term Life Insurance Portability Election Form

Group Term Life Insurance Portability Election Form Group Term Life Insurance Portability Election Form If you have been actively employed prior to leaving your employer, and you are not retiring or disabled, you may apply for Group Term Life Insurance

More information

A Description of the California Partnership for Long-Term Care Prepared by the California Department of Health Care Services

A Description of the California Partnership for Long-Term Care Prepared by the California Department of Health Care Services 2012 Before You Buy A Description of the Caifornia Partnership for Long-Term Care Prepared by the Caifornia Department of Heath Care Services Page 1 of 13 Ony ong-term care insurance poicies bearing any

More information

Group Term Life Insurance Portability Election Form

Group Term Life Insurance Portability Election Form Group Term Life Insurance Portability Election Form If you have been actively employed prior to leaving your employer, and you are not retiring or disabled, you may apply for Group Term Life Insurance

More information

Group Life Claim Form

Group Life Claim Form Group Life Claim Form Group Life Claims, P.O. Box 14334, Lexington, KY 40512 Customer Service: (800) 525-4542, Fax: (610) 807-8266 Documents can be returned electronically at www.guardiananytime.com. Click

More information

Your Critical Care policy is supplemental health insurance to help cover the additional expenses associated with a critical illness diagnosis.

Your Critical Care policy is supplemental health insurance to help cover the additional expenses associated with a critical illness diagnosis. Your Critical Care policy is supplemental health insurance to help cover the additional expenses associated with a critical illness diagnosis. The Critical Care Benefit is a one time lump sum payment.

More information

GROUP LIFE CLAIM KIT FOR PROCESSING LIFE INSURANCE AND ACCIDENTAL DEATH BENEFITS BY A THIRD PARTY ADMINISTRATOR

GROUP LIFE CLAIM KIT FOR PROCESSING LIFE INSURANCE AND ACCIDENTAL DEATH BENEFITS BY A THIRD PARTY ADMINISTRATOR GROUP LIFE CLAIM KIT FOR PROCESSING LIFE INSURANCE AND ACCIDENTAL DEATH BENEFITS BY A THIRD PARTY ADMINISTRATOR PLEASE SUBMIT THE FOLLOWING: INSTRUCTIONS FOR FILING A LIFE INSURANCE CLAIM 1. THE CLAIM

More information

Continue your Aetna life insurance coverage with these options.

Continue your Aetna life insurance coverage with these options. P.O. Box 24846 Cleveland OH 44124-0846 Group Life Insurance Operations Phone: 1-877-503-3448 Fax: 440-386-2662 Continue your Aetna life insurance coverage with these options. Thank you for your interest

More information

Group Life Claim Form

Group Life Claim Form Group Life Claim Form Group Life Claims, P.O. Box 26035, Lehigh Valley, PA 18002-6035 Customer Service: (800) 525-4542, Fax: (610) 807-8266 Secure E-mail: www.guardiananytime.com, click secure channel,

More information

Portability Option for Group Term Life Insurance

Portability Option for Group Term Life Insurance Instructions 1. Employer Please Print 2. Employee Please read the Fraud Notice on the back of the form, before completing. Please Print Portability Option for Group Term Life Insurance Aetna Life Insurance

More information

Group Term Life Insurance Portability Election Form

Group Term Life Insurance Portability Election Form Group Term Life Insurance Portability Election Form You may apply for Group Term Life Insurance coverage under Prudential s portability option. This option may be available to you and your covered dependents

More information

Amount Existing Liens $ Purpose of Refinance. 4. Applicant Information Co-Applicant's Name. Social Security No. Date of Birth.

Amount Existing Liens $ Purpose of Refinance. 4. Applicant Information Co-Applicant's Name. Social Security No. Date of Birth. Universa Credit Appication (Consumer Residentia Rea Estate) 1. Type of Appication (Check ony one of the four checkboxes; and sign, if joint credit) Individua Credit. If checked, this is an Appication for

More information

Group Term Life Insurance Continuation Form

Group Term Life Insurance Continuation Form Group Term Life Insurance Continuation Form Employees must be actively at work at the time of employment termination or retirement in order to be eligible for the continuation plan. Coverage terminates

More information

Group Life Claim Form for New York Residents

Group Life Claim Form for New York Residents Group Life Claim Form for New York Residents Group Life Claims, P.O. Box 26035, Lehigh Valley, PA 18002-6035 Customer Service: (800) 525-4542, Fax: (610) 807-8266 Secure E-mail: www.guardiananytime.com,

More information

Early access to FAS payments for members in poor health

Early access to FAS payments for members in poor health Financia Assistance Scheme Eary access to FAS payments for members in poor heath Pension Protection Fund Protecting Peope s Futures The Financia Assistance Scheme is administered by the Pension Protection

More information

Income Protection Options

Income Protection Options Income Protection Options Poicy Conditions Introduction These poicy conditions are written confirmation of your contract with Aviva Life & Pensions UK Limited. It is important that you read them carefuy

More information

Transamerica Premier Life Insurance Company

Transamerica Premier Life Insurance Company Insurance Claim Filing Instructions PROOF OF LOSS CONSISTS OF THE FOLLOWING: 1. A completed and signed Claim form and Attending Physician s Statement. 2. For Hospital/Intensive Care/Hospital Services Coverage

More information

Income Protection Solutions. Policy Wording

Income Protection Solutions. Policy Wording Income Protection Soutions Poicy Wording Wecome to Aviva This booket tes you a you need to know about your poicy, incuding: what to do if you need to caim what s covered, and expanations of some of the

More information

To file a claim: If you have any questions or need additional assistance, please contact our Claim office at 1-800-811-2696.

To file a claim: If you have any questions or need additional assistance, please contact our Claim office at 1-800-811-2696. The Accident Expense Plus policy is a financial tool that helps cover high deductibles, co-pays and other expenses not covered by your primary major medical plan. This supplemental plan reimburses you

More information

American General Assurance Company

American General Assurance Company American General Assurance Company Proof of Death Claim Claimant s Statement CLAIMANT S STATEMENT: COMPLETE, SIGN AND DATE THIS FORM, THE AUTHORIZATION FOR RELEASE OF INFORMATION AND THE FRAUD STATEMENT.

More information

ACCIDENT CLAIM FORM. Daytime telephone No. Patient s full name Date of birth Relationship to policyowner

ACCIDENT CLAIM FORM. Daytime telephone No. Patient s full name Date of birth Relationship to policyowner BOSTON MUTUAL LIFE INSURANCE COMPANY HOME OFFICE: 120 Royall Street Canton, MA 02021 ADMINISTERED BY: PHILADELPHIA AMERICAN LIFE INSURANCE COMPANY PO Box 34952 Omaha, NE 68134-9832 TEL 1-888-453-5120 FAX

More information

AIG Benefit Solutions Underwritten by American General Life Insurance Company*

AIG Benefit Solutions Underwritten by American General Life Insurance Company* Proof of Group Death Claim The United States Life Insurance Company in the City of New York PLEASE ANSWER ALL QUESTIONS FULLY AS THIS WILL HELP EXPEDITE THE EVALUATION OF THIS CLAIM. POLICYHOLDER S STATEMENT

More information

... HSA ... Health Savings Account. Custodial. (includes self-direction)

... HSA ... Health Savings Account. Custodial. (includes self-direction) HSA Heath Savings Account Custodia (incudes sef-direction) ADDITIONAL INFORMATION Purpose This Organizer contains documents necessary to estabish a Heath Savings Account (HSA) It meets the requirements

More information

Voluntary Group Term Life Insurance

Voluntary Group Term Life Insurance 0159297 Voluntary Group Term Life Insurance American Foreign Service Protective Association Voluntary Group Term Life Insurance Plan Up to $600,000 of Coverage Protect the Ones You Love Whatever is next

More information

Application to Continue/Port or Convert Group Insurance

Application to Continue/Port or Convert Group Insurance Application to Continue/Port or Convert Group Insurance Products and financial services provided by American United Life Insurance Company a OneAmerica company One American Square, P.O. Box 7106 Indianapolis,

More information

Monumental Life Insurance Company

Monumental Life Insurance Company Insurance Claim Filing Instructions PROOF OF LOSS CONSISTS OF THE FOLLOWING: 1. A completed and signed Claim form and Attending Physician s Statement. 2. For Hospital/Intensive Care/Hospital Services Coverage

More information

Policy Owner Address: Street City State ZIP Code

Policy Owner Address: Street City State ZIP Code TRUSTMARK INSURANCE COMPANY PO BOX 7937 LAKE FOREST IL 60045-7937 1-800-918-8877 FAX 1-847-615-3128 www.trustmarkins.com/customersolutions ACCIDENT CLAIM FORM This form must be completed by the attending

More information

Home Address (Street/PO Box) F M Date of Birth (mm/dd/yyyy) State Zip Code Home Phone # Scheduled Number of Work Hours per Week Work Phone #

Home Address (Street/PO Box) F M Date of Birth (mm/dd/yyyy) State Zip Code Home Phone # Scheduled Number of Work Hours per Week Work Phone # Unum Life Insurance Company of America 2211 Congress Street Portland, Maine 04122 APPLICATION FOR GROUP CRITICAL ILLNESS INSURANCE Evidence of Insurability Application Type: New Enrollee Change to Existing

More information

Employer Instructions for Filing Group Life Insurance Claims

Employer Instructions for Filing Group Life Insurance Claims Metropolitan Life Insurance Company Group Life Claims Employer Instructions for Filing Group Life Insurance Claims 1. Detach this page and complete the Employer s Statement on the following page. 2. Give

More information

Email Address Employee ID/Payroll # Employer Name Customer Number Date of Hire (mm/dd/yyyy)

Email Address Employee ID/Payroll # Employer Name Customer Number Date of Hire (mm/dd/yyyy) APPLICATION FOR GROUP CRITICAL ILLNESS INSURANCE Evidence of Insurability Unum Life Insurance Company of America ( Unum ) 2211 Congress Street Portland, Maine 04122 Application Type: Newly Eligible Late

More information

If your claim is within the policy s contestability period, we may request additional information.

If your claim is within the policy s contestability period, we may request additional information. Your Cancer Care policy is a limited benefit plan that is designed to supplement the cost of medical procedures and expenses due to the treatment of Cancer. There are three plan options available. Cancer

More information

You also may have purchased the Hospital Cash Rider and/or the Disability Income Benefit Rider. Refer to your policy for detail information.

You also may have purchased the Hospital Cash Rider and/or the Disability Income Benefit Rider. Refer to your policy for detail information. Your Emergency Care policy is supplemental insurance to help cover the additional expenses associated with an accidental injury. An Accident is defined as an unforeseen occurrence of an event, which results

More information

AIG Benefit Solutions Underwritten by

AIG Benefit Solutions Underwritten by Proof of Group Death Claim The United States Life Insurance Company in the City of New York* PLEASE ANSWER ALL QUESTIONS FULLY AS THIS WILL HELP EXPEDITE THE EVALUATION OF THIS CLAIM. POLICYHOLDER S STATEMENT

More information

Home Address (Street/PO Box) F M Date of Birth (mm/dd/yyyy) State Zip Code Home Phone # Scheduled Number of Work Hours per Week Work Phone #

Home Address (Street/PO Box) F M Date of Birth (mm/dd/yyyy) State Zip Code Home Phone # Scheduled Number of Work Hours per Week Work Phone # Unum Life Insurance Company of America 2211 Congress Street Portland, Maine 04122 APPLICATION FOR GROUP CRITICAL ILLNESS INSURANCE Evidence of Insurability Application Type: New Enrollee Change to Existing

More information

GROUP CRITICAL ILLNESS INSURANCE. Claim Forms and Instructions

GROUP CRITICAL ILLNESS INSURANCE. Claim Forms and Instructions GROUP Underwritten by: National Guardian Life Insurance Company Administered by: AlwaysCare Benefits, Inc. Claim Forms and Instructions We understand that suffering a critical illness creates emotional,

More information

A Guide for Successfully Completing the Group Life Insurance Evidence of Insurability Form

A Guide for Successfully Completing the Group Life Insurance Evidence of Insurability Form A Guide for Successfully Completing the Group Life Insurance Evidence of Insurability Form Mutual of Omaha appreciates the opportunity to provide you with valuable life insurance protection for yourself

More information

OUTPATIENT PHYSICIAN S TREATMENT CLAIM FORM

OUTPATIENT PHYSICIAN S TREATMENT CLAIM FORM OUTPATIENT PHYSICIAN S TREATMENT CLAIM FORM If you have any questions regarding benefits available, or how to file your claim, or if you would like to appeal any determination, please contact our Customer

More information

The Accelerated Benefits Option ( ABO )

The Accelerated Benefits Option ( ABO ) The Accelerated Benefits Option ( ABO ) Metropolitan Life Insurance Company Group Life Claims Telephone Number: 1-800-638-6420 Please read the following important information before completing the attached

More information

GROUP LIFE AND/OR ACCIDENTAL DEATH CLAIM FORM

GROUP LIFE AND/OR ACCIDENTAL DEATH CLAIM FORM For use with policies issued by the following Unum Group [ Unum ] subsidiaries: Unum Life Insurance Company of America Provident Life and Accident Insurance Company The Paul Revere Life Insurance Company

More information

ACCIDENT CLAIM FORM. 5. Was patient hospitalized? Yes No NAME OF HOSPITAL CITY STATE

ACCIDENT CLAIM FORM. 5. Was patient hospitalized? Yes No NAME OF HOSPITAL CITY STATE ACCIDENT CLAIM FORM INSTRUCTIONS: 1. Please make sure all questions are complete on this form. 2. If we request an authorization form from you, please complete, sign and date the authorization form we

More information

TRUSTMARK INSURANCE COMPANY

TRUSTMARK INSURANCE COMPANY TRUSTMARK INSURANCE COMPANY CRITICAL ILLNESS/CANCER CLAIM FORM 100 NORTH PARKWAY, SUITE 200 WORCESTER, MA 10605 1-800-918-8877 FAX 1-508-853-2867 www.trustmarkins.com/customersolutions This form must be

More information

NOTIFICATION OF INJURY

NOTIFICATION OF INJURY NOTIFICATION OF INJURY This Notification of Injury Form is to be used for accident medical claims. Policies With Excess Coverage Eligible covered expenses will be paid only if they are in excess of other

More information

Health Savings Account 2013 2014 reference guide

Health Savings Account 2013 2014 reference guide Heath Savings Account 2013 2014 reference guide Information at your fingertips This ist of chapters and page numbers wi hep you find the information you need quicky. A detaied ist of sections and topics

More information

NatWest Global Employee Banking Eastwood House Glebe Road Chelmsford Essex England CM1 1RS Depot Code 028

NatWest Global Employee Banking Eastwood House Glebe Road Chelmsford Essex England CM1 1RS Depot Code 028 To appy for this account, the printed appication must be competed and returned together with any necessary supporting documentation to the foowing address: NatWest Goba Empoyee Banking Eastwood House Gebe

More information

The forms must be completed by a qualified person and signed with their occupational title as per its respective form.

The forms must be completed by a qualified person and signed with their occupational title as per its respective form. Your ability to work and generate income is your greatest asset. If a disability ever left you unable to work, a combination of increased expenses and loss of income could create financial difficulties.

More information

Critical Illness Insurance Options

Critical Illness Insurance Options Critica Iness Insurance Options Poicy Summary Critica Iness Insurance Options This summary tes you the key things you need to know about our Critica Iness Insurance Options poicy. It doesn t give you the

More information

Continue your Aetna life insurance coverage with these options.

Continue your Aetna life insurance coverage with these options. Life Enrollment & Billing Services 151 Farmington Avenue, RT32 Hartford, CT 06156 Need more information? Log onto www.aetna.com, or call us at 1-800-523-5065 Continue your Aetna life insurance coverage

More information

NON-QUALIFIED ANNUITY DEATH CLAIM ELECTION FORM

NON-QUALIFIED ANNUITY DEATH CLAIM ELECTION FORM NON-QUALIFIED ANNUITY DEATH CLAIM ELECTION FORM To process your claim as quickly as possible, we need personal information about the beneficiary as well as information about the deceased annuitant or owner.

More information

This form is to be submitted for services rendered by a provider outside of the EyeMed provider network.

This form is to be submitted for services rendered by a provider outside of the EyeMed provider network. This form is to be submitted for services rendered by a provider outside of the EyeMed provider network. The fields can be completed as follows: } Vision Plan Name: Tufts Health Plan } Vision Plan/Group

More information

GROUP SHORT-TERM DISABILITY STATEMENT OF EMPLOYEE

GROUP SHORT-TERM DISABILITY STATEMENT OF EMPLOYEE GROUP SHORT-TERM DISABILITY STATEMENT OF EMPLOYEE 1. Full Name (last, first, middle initial) 2. Social Security Number 3. Phone Number (include area code) 4. Street Address & Mailing Address 5. City 6.

More information

Benefits That Count. Colonial Life is the proud sponsor of SHRM s Annual Employee Benefits Survey. coloniallife.com

Benefits That Count. Colonial Life is the proud sponsor of SHRM s Annual Employee Benefits Survey. coloniallife.com Benefits That Count Coonia Life is the proud sponsor of SHRM s Annua Empoyee Benefits Survey cooniaife.com 1 Dear Empoyer: Randa C. Horn President & CEO Coonia Life & Accident Insurance Company 1200 Coonia

More information

First Name MI Last. Street Address (P.O. Boxes cannot be accepted) City State Zip. First Name MI Last

First Name MI Last. Street Address (P.O. Boxes cannot be accepted) City State Zip. First Name MI Last Accident Claim Form Instructions for Filing a Claim LIFESECURE INSURANCE COMPANY ADMINISTRATIVE OFFICE ATTN: Claims Department PO Box 13490, Pensacola, FL 32591-3490 1-888-575-8246 Please have all sections

More information

Death Claim Form Group Life and Accidental Death Insurance

Death Claim Form Group Life and Accidental Death Insurance INSTRUCTIONS The employer/administrator must complete the claim form as indicated and send attachments mentioned below. We will advise you if further documentation is necessary to complete the claim process.

More information

1. Full Name (last, first, middle initial) 2. Social Security Number 3. Phone Number (include area code)

1. Full Name (last, first, middle initial) 2. Social Security Number 3. Phone Number (include area code) GROUP SHORT-TERM DISABILITY STATEMENT OF EMPLOYEE (BENEFITS MAY BE DELAYED IF CLAIM FORM IS NOT FULLY COMPLETED) Please sign this page and the authorization on page two of this form to avoid delays in

More information

Life Insurance Claimant s Statement

Life Insurance Claimant s Statement Life Insurance Claimant s Statement Policy Policy number(s) Information Name of Deceased Other names by which the deceased may have been known 55 No. 300 West, Suite 375 Salt Lake City, Utah 84101 (801)

More information

How To File a Claim. 1. Have Parent/Guardian of injured participant or injured adult participant complete and sign appropriate sections of claim form.

How To File a Claim. 1. Have Parent/Guardian of injured participant or injured adult participant complete and sign appropriate sections of claim form. How To File a Claim The Claim Form (M18979) is prepared by the Girl Scout volunteer or another authorized person, usually one who was at the scene of the accident and familiar with the circumstances. Volunteer

More information

How To File a Claim. 1. Have Parent/Guardian of injured participant or injured adult participant complete and sign appropriate sections of claim form.

How To File a Claim. 1. Have Parent/Guardian of injured participant or injured adult participant complete and sign appropriate sections of claim form. How To File a Claim The Claim Form (M18979) is prepared by the Girl Scout volunteer or another authorized person, usually one who was at the scene of the accident and familiar with the circumstances. Volunteer

More information

Budgeting Loans from the Social Fund

Budgeting Loans from the Social Fund Budgeting Loans from the Socia Fund tes sheet Pease read these notes carefuy. They expain the circumstances when a budgeting oan can be paid. Budgeting Loans You may be abe to get a Budgeting Loan if:

More information

GUARANTEE TRUST LIFE INSURANCE COMPANY Credit Claim Service Center P.O. Box 1145 Glenview, IL 60025 Phone: 800-592-0629 Fax: 847-460-2962

GUARANTEE TRUST LIFE INSURANCE COMPANY Credit Claim Service Center P.O. Box 1145 Glenview, IL 60025 Phone: 800-592-0629 Fax: 847-460-2962 Initial Credit Disability Claim Form GUARANTEE TRUST LIFE INSURANCE COMPANY Credit Claim Service Center P.O. Box 1145 Glenview, IL 60025 Phone: 800-592-0629 Fax: 847-460-2962 Office Hours: Monday thru

More information

CRITICAL ILLNESS CLAIMS

CRITICAL ILLNESS CLAIMS CRITICAL ILLNESS CLAIMS 777 Research Drive, Lincoln, NE 68521 1-866-863-9753 www.5starlifeinsurance.com Claim Instructions To report a Group Critical Illness claim, please contact our claims department

More information

Critical Illness. Claimant name Male Female Birth Date Claimant Social Security Number

Critical Illness. Claimant name Male Female Birth Date Claimant Social Security Number Fax to: Claims 1.866.611.9954 From: No# of pages: Or Mail to: P.O. Box 100266 Columbia SC 29202-3266 Critical Illness Please be sure to send the following Information: Medical Documentation for your condition,

More information

Vacancy Rebate Supporting Documentation Checklist

Vacancy Rebate Supporting Documentation Checklist Vacancy Rebate Supporting Documentation Checkist The foowing documents are required and must accompany the vacancy rebate appication at the time of submission. If the vacancy is a continuation from the

More information

Name of Employer Group Report # Sub-Code # (Sub-Division) Sub-Point # (Branch) Research Foundation for Mental Hygiene, Inc.

Name of Employer Group Report # Sub-Code # (Sub-Division) Sub-Point # (Branch) Research Foundation for Mental Hygiene, Inc. DISABILITY CLAIM FOR ACCIDENT & SICKNESS (A&S)/ SHORT TERM DISABILITY (STD)/SALARY CONTINUANCE Instructions for completing the claim form: 1. Complete all applicable areas of the claim form. Please print

More information

INSTRUCTIONS FOR FILING GROUP VOLUNTARY STD / LTD / WAIVER OF PREMIUM CLAIMS

INSTRUCTIONS FOR FILING GROUP VOLUNTARY STD / LTD / WAIVER OF PREMIUM CLAIMS CLAIM FORM AND INSTRUCTIONS If you have any questions regarding benefits available, or how to file your claim, or if you would like to appeal any determination, please contact our Customer Care Center

More information

INDUSTRIAL AND COMMERCIAL

INDUSTRIAL AND COMMERCIAL Finance TM NEW YORK CITY DEPARTMENT OF FINANCE TAX & PARKING PROGRAM OPERATIONS DIVISION INDUSTRIAL AND COMMERCIAL ABATEMENT PROGRAM PRELIMINARY APPLICATION AND INSTRUCTIONS Mai to: NYC Department of Finance,

More information

Accident Claim Form. (Not to be used if you are filing a disability claim)

Accident Claim Form. (Not to be used if you are filing a disability claim) Fax to: Claims 1.800.880.9325 From: No#of pages: Or Mail to: P.O. Box 100195 Columbia SC 29202-3195 Accident Claim Form (Not to be used if you are filing a disability claim) Please be sure to send the

More information

Hospital Indemnity Insurance Claim Form

Hospital Indemnity Insurance Claim Form Hospital Indemnity Insurance Claim Form Things to know before you begin If you are submitting a claim for a Hospitalization which you have not yet reported to us, please complete this claim form. Once

More information

Key Features of the Term Assurance (with options) For use in business protection planning

Key Features of the Term Assurance (with options) For use in business protection planning Key Features of the Term Assurance (with options) For use in business protection panning Term Assurance (with options) Key features The Financia Conduct Authority is a financia services reguator. It requires

More information

INDIVIDUAL LIFE CLAIM KIT FOR PROCESSING LIFE INSURANCE AND ACCIDENTAL DEATH BENEFITS INSTRUCTIONS FOR FILING A LIFE CLAIM

INDIVIDUAL LIFE CLAIM KIT FOR PROCESSING LIFE INSURANCE AND ACCIDENTAL DEATH BENEFITS INSTRUCTIONS FOR FILING A LIFE CLAIM INDIVIDUAL LIFE CLAIM KIT FOR PROCESSING LIFE INSURANCE AND ACCIDENTAL DEATH BENEFITS INSTRUCTIONS FOR FILING A LIFE CLAIM On behalf of Boston Mutual Life Insurance Company, please accept our sincere condolences

More information

POLICYHOLDER. Policy No.(s): Waiver of Premium (include life policies) Routine Pregnancy

POLICYHOLDER. Policy No.(s): Waiver of Premium (include life policies) Routine Pregnancy CLAIM FORM AND INSTRUCTIONS If you have any questions regarding our determination of your claim, or if you would like to appeal any determination, please contact our Customer Care Center at 1-800-348-4489

More information

CRITICAL ILLNESS CLAIM FORM

CRITICAL ILLNESS CLAIM FORM ACE American Insurance Company CRITICAL ILLNESS CLAIM FORM MAIL TO: Administrative Concepts, Inc. 994 Old Eagle School Road Suite 1005 Wayne, PA 19087-1802 www.visit-aci.com ENTIRE CLAIM FORM MUST BE COMPLETED

More information

Employer Instructions for Filing a Group Life Insurance Claim

Employer Instructions for Filing a Group Life Insurance Claim Anthem Life Insurance Company Life Claims Service Center P.O. Box 105448 Atlanta, GA 30348-5448 Phone 800-813-5682 Fax 877-305-3901 Email: lifeanddisabilityclaims@anthem.com Employer Instructions for Filing

More information

Key Features of Life Insurance

Key Features of Life Insurance Key Features of Life Insurance Life Insurance Key Features The Financia Conduct Authority is a financia services reguator. It requires us, Aviva, to give you this important information to hep you to decide

More information

State of Louisiana All Employees

State of Louisiana All Employees State of Louisiana All Employees Basic Term Life Insurance Basic plus Supplemental Term Life Insurance Accidental Death and Dismemberment Insurance Dependent Term Life Insurance The Prudential Insurance

More information

Death Claim Form Group Life and Accidental Death Insurance

Death Claim Form Group Life and Accidental Death Insurance INSTRUCTIONS Upon the death of an insured employee, plan member or insured dependent, the employer/administrator must complete the claim form as indicated and send attachments mentioned below. Be advised

More information

LIFE CLAIM KIT FOR PROCESSING LIFE INSURANCE AND ACCIDENTAL DEATH BENEFITS

LIFE CLAIM KIT FOR PROCESSING LIFE INSURANCE AND ACCIDENTAL DEATH BENEFITS LIFE CLAIM KIT FOR PROCESSING LIFE INSURANCE AND ACCIDENTAL DEATH BENEFITS INSTRUCTIONS FOR FILING A LIFE CLAIM On behalf of Boston Mutual Life Insurance Company, please accept our sincere condolences

More information

CRITICAL ILLNESS CLAIM FORM

CRITICAL ILLNESS CLAIM FORM The Lincoln National Life Insurance Company, PO Box 82087, Lincoln, NE 68501-2087 toll free (877) 815-9256 Fax (877) 668-5331 www.lincolnfinancial.com CRITICAL ILLNESS CLAIM FORM To Be Completed by the

More information

Health Savings Account 2014-2015 reference guide

Health Savings Account 2014-2015 reference guide Heath Savings Account 2014-2015 reference guide www.seectaccount.com Information at your fingertips This ist of chapters and page numbers wi hep you find the information you need quicky. A detaied ist

More information

INVOICE FOR INDEPENDENT HEALTH CARE PROVIDERS

INVOICE FOR INDEPENDENT HEALTH CARE PROVIDERS Attn: LTCI Claims P.O. Box 40007 Lynchburg, VA 24506-9939 Tel: 800 876.4582 Fax: 888 557.5526 Add this page to your Favorites list for the next time you need Invoices! Use this form to record the time

More information

NATIONWIDE LIFE INSURANCE COMPANY NATIONAL CASUALTY COMPANY NATIONWIDE SPECIALTY INSURANCE CLAIM FORM INSTRUCTIONS

NATIONWIDE LIFE INSURANCE COMPANY NATIONAL CASUALTY COMPANY NATIONWIDE SPECIALTY INSURANCE CLAIM FORM INSTRUCTIONS NATIONWIDE LIFE INSURANCE COMPANY NATIONAL CASUALTY COMPANY NATIONWIDE SPECIALTY INSURANCE CLAIM FORM INSTRUCTIONS THIS CLAIM CANNOT BE PROCESSED WITHOUT ALL OF THE BELOW INFORMATION AND STATEMENTS OF

More information

Employer Instructions for Filing Group Life Insurance Claims

Employer Instructions for Filing Group Life Insurance Claims Group Life Claims Employer Instructions for Filing Group Life Insurance Claims 1. Detach this page and complete the Employer s Statement on the following page. 2. Give the beneficiary the remaining pages

More information

APPLICATION FOR GROUP TERM LIFE INSURANCE Underwritten by The United States Life Insurance Company in the City of New York (Herein called the Company)

APPLICATION FOR GROUP TERM LIFE INSURANCE Underwritten by The United States Life Insurance Company in the City of New York (Herein called the Company) APPLICATION FOR GROUP TERM LIFE INSURANCE Underwritten by The United States Life Insurance Company in the City of New York (Herein called the Company) Member information (Please print or type) Name APTA

More information

INSTRUCTIONS FOR FILING GROUP VOLUNTARY STD / LTD / WAIVER OF PREMIUM CLAIMS

INSTRUCTIONS FOR FILING GROUP VOLUNTARY STD / LTD / WAIVER OF PREMIUM CLAIMS CLAIM FORM AND INSTRUCTIONS If you have any questions regarding our determination of your claim, or if you would like to appeal any determination, please contact our Customer Care Center at 1-800-348-4489

More information

Accidental Dismemberment Insurance Claim Form

Accidental Dismemberment Insurance Claim Form State of Florida Account Participating Agencies and Departments Payroll Deduction Code 262 Mail To: Cigna P.O. Box 22328 Pittsburgh, PA 15222-0328 1-800-238-2125 Toll Free Claims administered by Cigna

More information

What to Expect Whe n Yo u Ha v e A Cl a i m

What to Expect Whe n Yo u Ha v e A Cl a i m 10. Can I fax my claim form? Yes, we can accept faxes at 508-853-2867; we also ask that the original be sent via mail. Our fax number appears in the upper left-hand corner of our Claim Forms for your convenience.

More information

Critical Illness Claim Filing Instructions

Critical Illness Claim Filing Instructions Critical Illness Claim Filing Instructions The offering Company(ies) listed below, severally or collectively, as the content may require, are referred to in this authorization as We or Humana. Life, Specified

More information

Application for Conversion of Group Term Life and Accidental Death Insurance Aetna Life Insurance Company

Application for Conversion of Group Term Life and Accidental Death Insurance Aetna Life Insurance Company Application for Conversion of Group Term Life and Accidental Death Insurance Aetna Life Insurance Company Application and payment of the first premium must be made within the time limit shown in your certificate

More information

NATIONWIDE LIFE INSURANCE COMPANY NATIONAL CASUALTY COMPANY NATIONWIDE SPECIALTY INSURANCE CLAIM FORM

NATIONWIDE LIFE INSURANCE COMPANY NATIONAL CASUALTY COMPANY NATIONWIDE SPECIALTY INSURANCE CLAIM FORM NATIONWIDE LIFE INSURANCE COMPANY NATIONAL CASUALTY COMPANY NATIONWIDE SPECIALTY INSURANCE CLAIM FORM THIS CLAIM CANNOT BE PROCESSED WITHOUT ALL OF THE BELOW INFORMATION AND STATEMENTS OF PAYMENTS FROM

More information

Hole-In-One Application

Hole-In-One Application > Hole-In-One Application All questions must be answered in full. Application must be signed and dated by the applicant.

More information

Leaders Life Insurance Accident Claim Filing Instructions

Leaders Life Insurance Accident Claim Filing Instructions Leaders Life Insurance Accident Claim Filing Instructions Page One Filing Instructions: Complete the appropriate sections of the claim form (page 2) Attach an itemized billing from your provider which

More information

Toll-free: 1-800-635-5597 Fax: 1-800-447-2498 Call toll-free Monday through Friday, 8 a.m. to 8 p.m. Eastern Time.

Toll-free: 1-800-635-5597 Fax: 1-800-447-2498 Call toll-free Monday through Friday, 8 a.m. to 8 p.m. Eastern Time. For use with policies issued by the following Unum Group [ Unum ] subsidiaries: Unum Life Insurance Company of America Provident Life and Accident Insurance Company OUR COMMITMENT TO YOU You have our commitment

More information

You can relax, knowing your final wishes will be respected.

You can relax, knowing your final wishes will be respected. Memorial Fund You can relax, knowing your final wishes will be respected. Humana Financial Protection Products GNA06XOHH 11/09 MI Memorial Fund Ensure financial peace of mind for you and your family. You

More information

NEXT PAGE. Applicant information (Please print or type) Name. Are you a: Member Spouse Domestic Partner* If Spouse/Domestic Partner, Name of Member

NEXT PAGE. Applicant information (Please print or type) Name. Are you a: Member Spouse Domestic Partner* If Spouse/Domestic Partner, Name of Member APPLICATION FOR GROUP LEVEL TERM LIFE INSURANCE Underwritten by The United States Life Insurance Company in the City of New York (Herein called the Company) Applicant information (Please print or type)

More information

Critical Illness Insurance Claim Form

Critical Illness Insurance Claim Form Critical Illness Insurance Claim Form Things to know before you begin If you are submitting a claim for a Critical Illness which you have not yet reported to us, please complete this claim form. Once we

More information

Toll-free: 1-800-635-5597 Fax: 1-800-447-2498 Call toll-free Monday through Friday, 8 a.m. to 8 p.m. Eastern Time.

Toll-free: 1-800-635-5597 Fax: 1-800-447-2498 Call toll-free Monday through Friday, 8 a.m. to 8 p.m. Eastern Time. For use with policies issued by the following Unum Group [ Unum ] subsidiaries: Unum Life Insurance Company of America Provident Life and Accident Insurance Company OUR COMMITMENT TO YOU We understand

More information

Income Protection Solutions. Policy Wording

Income Protection Solutions. Policy Wording Income Protection Soutions Poicy Wording Wecome to Aviva This booket tes you a you need to know about your poicy, incuding: what to do if you need to caim what s covered, and expanations of some of the

More information

DISABILITY INCOME/OFFICE OVERHEAD EXPENSE CLAIM INSTRUCTIONS (PLEASE KEEP THIS NOTICE FOR FUTURE REFERENCE)

DISABILITY INCOME/OFFICE OVERHEAD EXPENSE CLAIM INSTRUCTIONS (PLEASE KEEP THIS NOTICE FOR FUTURE REFERENCE) DISABILITY INCOME/OFFICE OVERHEAD EXPENSE CLAIM INSTRUCTIONS (PLEASE KEEP THIS NOTICE FOR FUTURE REFERENCE) Please answer all questions on the Member s Statement of your Disability Income/Office Overhead

More information

ACCIDENT PLAN CLAIM FORM

ACCIDENT PLAN CLAIM FORM The Lincoln National Life Insurance Company, PO Box 82087, Lincoln, NE 68501-2087 toll free (877) 815-9256 Fax (877) 668-5331 www.lincolnfinancial.com ACCIDENT PLAN CLAIM FORM How To Use this Form to File

More information

FIRST BANK OF MANHATTAN MORTGAGE LOAN ORIGINATORS NMLS ID #405508

FIRST BANK OF MANHATTAN MORTGAGE LOAN ORIGINATORS NMLS ID #405508 ITEMS TO BE SUBMITTED WITH HOME EQUITY LOAN APPLICATION Bring In: Pay stubs from the ast 30 days W-2 s and Tax Returns from the ast 2 years Bank Statements from ast 2 months (A Pages) Copy of Homeowner

More information

Accident insurance plain claim form

Accident insurance plain claim form The Lincoln National Life Insurance Company PO Box 82087, Lincoln, NE 68501-2087 toll free (800) 423-2765 Fax (877) 843-3950 www.lincolnfinancial.com Accident insurance plain claim form Policy Holder Information

More information