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 ClaimsClaim FormsMarketing Names of Products Using the Claim Forms
Accident Claim Form GNHH5LOHHAccident Income Plus, Individual Axium, Group Axium
Cancer Wellness Claim Form GNHH5LPHH
Cash Cancer Claim Form GNHH5LTHH
Critical Illness Claim FormGNHH5M2HHCritical Advantage
Critical Illness & Supplemental Health Wellness Claim Form GNHH5LZHHCritical Advantage
Workplace Voluntary Disability - Initial Claim Form (Policy number should be 10 digits)GNHH5M6HHAegis (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) GNHH5M0HHAegis (Individual and Group), Disability Income Plus, Income Protector, Paycheck Protector (Worksite & Direct), Disability Income Advantage
Monthly Disability Short Form5052Aegis (Individual and Group), Disability Income Plus, Income Protector, Paycheck Protector (Worksite & Direct), Disability Income Advantage
Facility Care Claims5901Facility Care Rider
Healthcare Plus Wellness Claim Form GNHH5M3HH
Individual Life Claim FormGCA09JHHH5 Year Term, 10 Year Term, Aegis (Individual and Group) LPU 65, LPU 95, Mortgage Term, Secure Life
Supplemental Health, Hospital Indemnity, Healthcare Plus Claim FormGNHH5M5HHHealth Care Plus
Medicare Supplement Claims5064All Kanawha Medicare Supplement products
Voluntary Benefits Portability Election Form1676
Workplace Voluntary Disability - Maternity Claim Form (Policy number should be 10 digits)GNHH5M8HH