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) | 6016 – 6016 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 |
