HR Professional: Service/Enrollment Forms

Group Core Benefits
General Forms
Employee Request for Change Form 1475
Premium Remittance Form 1476
Waiver of Group Insurance Form 1504 - State:
Affidavit of Domestic Partnership 5841 - State:
Statement of Termination of Domestic Partnership 5847 - State:
Group Disability Insurance (LTD/STD)
Group Disability Enrollment Form 1493 - State:
Group Disability Evidence of Insurability 1490 - State:
STD Claim Form LC-5180-18 - State:
LTD Claim Form LC-4571-18 - State:
Group Term Life
Claim Statement Life/AD&D 5114 - State:
Group Term Life Enrollment Form (Employer Groups) 1465 - State:
Group Term Life Enrollment Form (Association Groups) 1466 - State:
Group Term Life Insurance Evidence of Insurability (EOI) Form 1474 - State:
Waiver Claim Form 5088 - State:
Group Term Life Insurance Portability Election Form 1488
Group Insurance Beneficiary Designation/Change 6249 - State:
Absolute Assignment of Group Life Insurance Benefits 6271 - State:
Notice of Conversion Right 5258 - State:
Stop Loss
Aggregate Excess Risk Claim Notification 1487
Specific Excess Risk Claim Notification 1479
Voluntary (Worksite) Benefits
Types of Claims Claim Forms Marketing Names of Products Using the Claim Forms
Accident Claims 6554 Accident Income Plus, Individual Axium, Group Axium
Cancer Claims (CA is State Specific) 5057 1/99 - 5057 CA Cancer Care, Cancer Plus
Cancer Claims, ULA policies only 5057 1/99 ULA ULA Cancer Policy Only
Cancer Claims, First Diagnosis/Lump Sum Only (CA is State Specific) 5228 - 5228 CA Cash Cancer Plan, Cash Cancer Plus
Critical Illness Claims (CA is State Specific) 5203 - 5203 CA Synergis; Aegis (Individual and Group)
Critical Illness Claim From 6445 Critical Advantage
Dental Claims 5068 Dental Plus, Group Dental Plus
Disability Claims (CA is State Specific) 5169 - 5169 CA Aegis (Individual and Group), Disability Income Plus, Income Protector, Paycheck Protector (Worksite & Direct)
Disability Income Advantage Claims 5124 Disability Income Advantage
Disability Supplemental Claims 5052 Aegis (Individual and Group), Disability Income Plus, Income Protector, Paycheck Protector (Worksite & Direct), Disability Income Advantage
Facility Care Claims 5901 Facility Care Rider
Home Health Care Claims 5213 Dependable Care at Home
Hospital Indemnity Claims 5043 Hospital Indemnity plus
Life of Virginia Medical Indemnity Claims 5111 Life of Virginia medical policies Only
Life/Death Claims (CA is State Specific) 5044 - 5044 CA 5 Year Term, 10 Year Term, Aegis (Individual and Group) LPU 65, LPU 95, Mortgage Term, Secure Life
Long Term Care, Tax Qualified Claims 5216 Dependable Care, Dependable Care Plus, Dependable Care III
Long Term Care, Non-Tax Qualified Claims 5039 Aegis (Individual and Group), Dependable Care, Dependable Care Plus, Dependable Care III
Medical Indemnity Claims 5095 Health Care Plus
Medical Indemnity Claims, Life of Virginia policies only 5111 Life of Virginia medical policies Only
Medicare Supplement Claims 5064 All Kanawha Medicare Supplement products
NCFlex Supplemental Claims 5256 NCFlex Supplemental Medical Only
Voluntary Benefits Portability Election Form 1676