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Service & Claims Forms

Claim Forms (PDF) - English
Cancer Claim – Individual Insurance – First Diagnosis/Lump Sum Only 5228 – 5228 CA
Cancer Claim Form 6740
Claim Form for Accident Policy 6554
Claim Form – Critical Illness, Critical Advantage 6445
Claim Form – Life 5044 – 5044 CA – 5044 ULA – 5044 ING – 5044 ING CA
Claim Form for Disability Income Insurance Policy 5169 – 5169 CA
Critical Illness Claim Form 5624
Supplemental Claimant's Statement 5052
Supplemental Health Claim Form 6785
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
Bankdraft Authorization 6027
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
Standard Change of Beneficiary Form 6042
Statement of Additional Coverage 1358
Termination of Payroll Deduction 6000
Voluntary Benefits Cancellation Request 1618
Voluntary Benefits Portability Election 1676

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