HR Professional: Service/Enrollment Forms

Group Core Benefits
General Forms
Employee Request for Change Form	1475
Premium Remittance Form	1476
Initial Waiver of Premium Claim Form	GNHH5M7HH
Waiver of Premium Continuation Claim Form	GNHH5M1HH
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:
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 Claim Form	GNHH5LOHH	Accident Income Plus, Individual Axium, Group Axium
Cancer Wellness Claim Form	GNHH5LPHH
Cash Cancer Claim Form	GNHH5LTHH
Critical Illness Claim Form	GNHH5M2HH	Critical Advantage
Critical Illness & Supplemental Health Wellness Claim Form	GNHH5LZHH	Critical Advantage
Workplace Voluntary Disability - Initial Claim Form (Policy number should be 10 digits)	GNHH5M6HH	Aegis (Individual and Group), Disability Income Plus, Income Protector, Paycheck Protector (Worksite & Direct), Disability Income Advantage
Workplace Voluntary Disability - Extension Claim Form (Policy number should be 10 digits)	GNHH5M0HH	Aegis (Individual and Group), Disability Income Plus, Income Protector, Paycheck Protector (Worksite & Direct), Disability Income Advantage
Monthly Disability Short Form	5052	Aegis (Individual and Group), Disability Income Plus, Income Protector, Paycheck Protector (Worksite & Direct), Disability Income Advantage
Facility Care Claims	5901	Facility Care Rider
Healthcare Plus Wellness Claim Form	GNHH5M3HH
Individual Life Claim Form	GCA09JHHH	5 Year Term, 10 Year Term, Aegis (Individual and Group) LPU 65, LPU 95, Mortgage Term, Secure Life
Supplemental Health, Hospital Indemnity, Healthcare Plus Claim Form	GNHH5M5HH	Health Care Plus
Medicare Supplement Claims	5064	All Kanawha Medicare Supplement products
Voluntary Benefits Portability Election Form	1676
Workplace Voluntary Disability - Maternity Claim Form (Policy number should be 10 digits)	GNHH5M8HH