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Service & Claims Forms

Claim Forms (PDF) - English
Accelerated Benefit Claim Form Accelerated Benefit Claim Form
Accident Claim Accident Claim
Cancer Plan – Wellness Benefit Claim Cancer Plan – Wellness Benefit Claim
Cash Cancer Claim Cash Cancer Claim
Critical Illness and Supplemental Health – Health Screening Benefit Claim Critical Illness and Supplemental Health – Health Screening Benefit Claim
Critical Illness Claim Critical Illness Claim
HealthCare Plus – Annual Physical Claim HealthCare Plus – Annual Physical Claim
Individual Life Claim Form Individual Life Claim Form
Waiver of Premium Claim Form Waiver of Premium Claim Form
Continuing Waiver of Premium Claim Form Continuing Waiver of Premium Claim Form
Supplemental Health, Hospital Indemnity and Healthcare Plus Claim Supplemental Health, Hospital Indemnity and Healthcare Plus Claim
Workplace Voluntary Disability Claim Form Workplace Voluntary Disability Claim Form
Workplace Voluntary Continuing Disability Claim Form Workplace Voluntary Continuing Disability Claim Form
Workplace Voluntary Disability - Maternity Express Disability Claim Form Maternity Express Disability Claim Form (To use this claim form your policy number should be 10 digits)
Workplace Voluntary Disability - Supplemental Claimants Statement 5052
Service/Miscellaneous Forms (PDF) - English
Absolute Assignment and Beneficiary Change 1031
Accumulated Dividends Form 6096
Acknowledgement of Nonduplication – Texas only 1307
Amendment to Application 1110
Authorization For the Use and Disclosure of Protected Health Information (for Underwriting) 1390
Bank Draft Authorization 6786
Beneficiary Designation Form GNHHG5DHH
Charitable Giving Beneficiary Form 1629
Direct Deposit Authorization 8172
Disclosure – Accelerated Benefit for Terminal Illness 1505
Facility Care Acceleration form on Whole Life 5901
Medical Consent Release 1311
Non-English Fluent and Literate Applicants – Amendment of Application for Insurance 1494
Non-English Fluent and Literate Applicants – Request for Waiver of Standard Procedures 1437
Notice Regarding Standards for Medi-Cal Eligibility 789.8 Notice CA
Payor Change Request 6020
Policy Values to Pay Premiums 6004
Policy Service Request (Loans, CSVs) 60166016 C
Reinstatement Form – Life/Health 6032
Replacement Form – Life 8131 – State:
Request for the Exchange of Insurance Policies Under Section 1035 of the Internal Revenue Service Code 1338
Statement of Additional Coverage 1358
Termination of Payroll Deduction 6000
Voluntary Benefits Cancellation Request 1618
Voluntary Benefits Portability Election 1676
Printable Health Insurance Page From Humana