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