If you’re covered for group life, disability, or dental insurance, or if you administer group benefits, you can access a variety of frequently used forms.
I’d like a form for:
| Form Number | Description |
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Accident Insurance and Accident Disability Insurance
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| GVACFM-7259 | Accident Claim Statement (H2) |
| GVACPK-3542 | Accident Portability Kit |
| GCIFM-7261 | Wellness / Cancer Screening |
| GVACFM-4165 | Accident Portability Claim Statement |
| GCIFM-7398 | Supplemental Claim Statement |
| GVACPK-4179 | Accident Continuation Kit |
| GMPAP-3430 | Voluntary Portability Application |
| GMPFM-2690 | Voluntary Portability Notice |
| GMPAP-3430 (CA) | Voluntary Portability Application (CA) |
| GMPAP-3430 (DC) | Voluntary Portability Application (DC) |
| GMPAP-3430 (GA) | Voluntary Portability Application (GA) |
| GMPAP-3430 (ID) | Voluntary Portability Application (ID) |
| GMPAP-3430 (MD) | Voluntary Portability Application (MD) |
| GMPAP-3430 (ME) | Voluntary Portability Application (ME) |
| GMPAP-3430 (MT) | Voluntary Portability Application (MT) |
| GMPAP-3430 (NJ) | Voluntary Portability Application (NJ) |
| GMPAP-3430 (PA) | Voluntary Portability Application (PA) |
| GMPAP-3430 (UT) | Voluntary Portability Application (UT) |
| GMPAP-3430 (VA) | Voluntary Portability Application (VA) |
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Cancer
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| GCIFM-7643 | Cancer Claim Statement |
| GCIPK-7801 | Cancer Portability Kit |
| GCIFM-7261 | Wellness / Cancer Screening |
| GCIPK-7802 | Cancer Continuation Kit |
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Critical Illness
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| GCIFM-7643 | Cancer Claim Statement |
| GCIFM-2831 | Critical Illness Employee Statement |
| GCIPK-4011 | Critical Illness HSA Continuation Kit |
| GCIPK-7801 | Cancer Portability Kit |
| GCIFM-2830 | Critical Illness Attending Physician Statement |
| GCIFM-7258 | Critical Illness Claim Statement (H2) |
| GCIFM-7261 | Wellness / Cancer Screening |
| GCIPK-7802 | Cancer Continuation Kit |
| GCIFM-7398 | Supplemental Claim Statement |
| GMPAP-3430 | Voluntary Portability Application |
| GMPFM-2690 | Voluntary Portability Notice |
| GMPAP-3430 (CA) | Voluntary Portability Application (CA) |
| GMPAP-3430 (DC) | Voluntary Portability Application (DC) |
| GCIPK-3537 | Critical Illness HSA Portability Kit |
| GCIFM-4132 | Critical Illness Portability - Employee Statement |
| GMPAP-3430 (GA) | Voluntary Portability Application (GA) |
| GCIFM-4151 | Critical Illness Portability - Attending Physician Statement |
| GMPAP-3430 (ID) | Voluntary Portability Application (ID) |
| GMPAP-3430 (MD) | Voluntary Portability Application (MD) |
| GMPAP-3430 (ME) | Voluntary Portability Application (ME) |
| GMPAP-3430 (MT) | Voluntary Portability Application (MT) |
| GMPAP-3430 (NJ) | Voluntary Portability Application (NJ) |
| GMPAP-3430 (PA) | Voluntary Portability Application (PA) |
| GMPAP-3430 (UT) | Voluntary Portability Application (UT) |
| GMPAP-3430 (VA) | Voluntary Portability Application (VA) |
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|
Customized Disability
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| GVCDFM-3042 | Customized Disability Employer Statement |
| GVCDFM-3043 | Customized Disability Employee Statement |
| GVCDFM-3044 | Customized Disability Attending Physician Statement |
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|
Dental and Vision
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| GDFM-7325 | Dental Claim Statement |
| GDFM-7326 | Dental Claim Statement (Prepaid) (NY and non-NY) |
| XGR/2262 | Dental Claim Form - Legacy SLHIC |
| VISION_VSP_REIMBURSE | Vision Request for Reimbursement - VSP |
| HIPAA-Notice-Privacy | HIPAA Notice of Privacy Practices |
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Enrollment
|
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| OCC_LTD_2015DI_NH | Outline of Coverage - LTD Only (2015DI) (NH) |
| OCC_LTD_2016DI_NH | Outline of Coverage - LTD Only (2016DI) (NH) |
| OCC_STD_2016DI_MT | Outine of Coverage - STD Only (2016DI) (MT) |
| GMPFM-2560 | Refusal of Non-Contributory Coverage |
| GMPFM-2560 (SLHIC) | Refusal of Non-Contributory Coverage (SLHIC) |
| OOC_CANCER-ONLY | Outline of Coverage - Cancer Only |
| OOC-CI-HSA | Outline of Coverage - Critical Illness - HSA |
| OOC_CI-NON-HSA | Outline of Coverage - Critical Illness - Non-HSA |
| OOC_CI-CANCER-HSA | Outline of Coverage - Critical Illness - Cancer - HSA |
| OOC_CI-CANCER-NONHSA | Outline of Coverage - Critical Illness - Cancer - Non-HSA |
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|
Evidence of Insurability
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| GMPAP-3040 | EOI Application-All states except what's listed individually |
| XGR/1470 | EOI Application (non-CI) (CA) |
| GMPAP-3040 (CT) | EOI application (CT) |
| XGR/1467 | EOI Application (FL) |
| GMPAP-3040 (FL) | EOI Application (CDI only) (FL) Lg cases |
| GMPAP-3040 (GA) | EOI Application (GA) |
| GMPAP-3040 (ID) | EOI Application (ID) |
| GMPAP-3040 (IN) | EOI Application (IN) |
| GMPAP-3040 (KS) | EOI Application (KS) |
| GMPAP-3040 (KY) | EOI Application (KY) |
| GLFM-2055 | EOI Cover Page Instructions |
| GMPAP-3040 (MA) | EOI Application (MA) |
| GMPAP-3040 (MD) | EOI Application (MD) |
| GMPAP-3040 (ME) - SLOC | EOI Application (ME) - SLOC |
| GMPAP-3040 (ME) - SLHIC | EOI Application (ME) - SLHIC |
| GMPAP-3040 (MN) | EOI Application (MN) |
| GMPAP-3040 (MT) | EOI Application (MT) |
| GMPAP-3040 (NE) | EOI Application (NE) |
| XGR/1466 | EOI Application (For use in: NH, MO, and UT) |
| GMPAP-3040 (NJ) SLOC | EOI Application (NJ) SLOC |
| GMPAP-3040 (NJ) SLHIC | EOI Application (NJ) SLHIC |
| GMPAP-3040 (NM) | EOI Application (NM) |
| GMPAP-3040 (OH) | EOI Application (OH) |
| XGR/1472 | EOI Application (OR) |
| GMPAP-3040 (RI) | EOI Application (RI) |
| XGR/1497 | EOI Application (VT) |
| GLFM-2247 | HIPAA Authorization for Medical Underwriting |
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Evidence of Insurability - Critical Illness only
|
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| GVFM-3637 CI | EOI Application - CI (Generic) |
| GVFM-3637 CI (AK) | EOI Application - CI (AK) |
| GVFM-3637 CI (CA) | EOI Application - CI (CA) |
| GVMPAP-6099 CI Only | EOI Application - For Use In CO |
| GVFM-3637 CI (CT) | EOI Application - CI (CT) |
| GVFM-3637 (FL) Lg | EOI Application - CI (FL) Lg cases |
| GVFM-3637 CI (ID) | EOI Application - CI (ID) |
| GVFM-3637 CI (IN) | EOI Application - CI (IN) |
| GVFM-3637 CI (KY) | EOI Application - CI (KY) |
| GVFM-3637 CI (MD) | EOI Application - CI (MD) |
| GVFM-3637 CI (ME) | EOI Application - CI (ME) |
| GVFM-3637 CI (MN) | EOI Application - CI (MN) |
| GVFM-3637(MO) | EOI Application - CI (MO) |
| GVFM-3637 CI (NC) | EOI Application - CI (NC) |
| GVFM-3637 CI (NE) | EOI Application - CI (NE) |
| GVFM-3637 (NH) | EOI Application - CI (NH) |
| GVFM-3637 CI (OH) | EOI Application - CI (OH) |
| GVFM-3637 (OR) | EOI Application - CI (OR) |
| GVFM-3637 CI (RI) | EOI Application - CI (RI) |
| GVFM-3637 (UT) | EOI Application - CI (UT) |
| GVFM-3637 CI (VA) | EOI Application - CI (VA) |
| GVFM-3637 CI (VT) | EOI Application - CI (VT) |
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|
FMLA
|
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| XGR/2255 | Mandatory Notice (NJ) - SLHIC (U.S.) |
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GAP
|
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| GVFM-9144 | Hospital Confinement "GAP" Claim |
| KC4739FSL / GVFM-8239 | Req to Elect Grp Hospital Indemnity Gap Ins COBR |
| KC4739FSLS / GVFM-8239-S | Formulario De Reclamacion-El Seguro (GAP) De Indemnizac |
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|
Hospital Indemnity
|
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| GHIFM-9529 | Hospital Indemnity Claim (H2) |
| HIPK-9923 | Hospital Indemnity Portability Kit |
| HIPK-9924 | Hospital Indemnity Continuation Kit |
| GHIFM-9529 (NY) | Hospital Indemnity Claim (NY) |
| GHIFM-9529-NY-PM | Online Hospital Indemnity Claim (NY) |
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|
Life and AD&D
|
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| GLFM-9073 | Life Conversion Notice (NY and non-NY) |
| GLFM-9018 | Life Conversion and Portability Notice (NY and non-NY) |
| GLFM-9072 | Life Conversion / Continuation Notice (NY and non-NY) |
| GLFM-9084 | Life Conversion for Waiver of Premium/Portability Transition |
| GLFL-9066 | Life Conversion Flyer |
| GLFM-1233 | Beneficiary Designation |
| GLFM-1233-Comm-Prop | Beneficiary Designation - Community Property |
| GLFM-1233-SP | Beneficiary Designation - Spanish |
| GLFM-6846 | Group Life Claims ADL & Cognitive Impairment Questionnaire |
| GLFM-2055 | EOI Cover Page Instructions |
| GLFM-5201 | SS90: Continuation Notice (MN) |
| GLFM-5203 | SS90 Life Continuation Election form (MN) |
| GR/2664 (MN) | SS90 Life Continuation Kit (MN) |
| GLPK-EE-6411 - LF15 | LIFE2015: Life Insurance Portability Kit |
| GLFM-7551 | Group Death Claim Packet: Claimant Statement |
| GMPFM-2690 | Voluntary Portability Notice |
| GLFM-7552 | Group Death Claim Packet: Employer Statement |
| GLFM-7791 | Group Life Benefits Claim Packet - Employer |
| GLFM-7793 | Group Life Benefits Claim Packet - Attending Physician |
| GLFM-7792 | Group Life Benefits Claim Packet - Employee |
| GLFM-9506 (MN) | 2015 Life Continuation - MN State Election and Notice |
| GLFM-9596 | Death Benefit Claim Authorization |
| GLFM-9297 | Life Direct Deposit Authorization |
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|
Long Term Disability
|
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| GDIFM-9683 | Disability Claim - Behavioral Health Treating Provider Stmt |
| GDIFM-8705 | Disability Transition Claim |
| GGFM-3803 | Disability Direct Deposit Authorization |
| GDIFM-8649 | Reimbursement Agreement |
| GLTDFM-3085 | Social Security / Retirement Status |
| GDIFM-8650 | Third Party Authorization |
| GLTDFM-4275 | LTD Conversion Notice |
| GLTDFM-5441 | Personal Profile Summary |
| GLTDFM-5007 (SLOC) | SLOC LTD Activities of Daily Living Questionnaire |
| GLTDFM-5007 (SLHIC-NY) | SLHIC-NY LTD Activities of Daily Living Questionnaire |
| XGR/1143 | Info Request: Training/Education |
| XGR/464 | LTD Conversion Application |
| GMPFM-2690 | Voluntary Portability Notice |
| GLTDFM-5418 | Look-Back Percentage Form |
| GDIFM-8916 | W-2 Tax Reporting Service Agreement |
| GDIFM-10426 | ER FICA Match with W-2 Tax Reporting Service Agreement |
| GLTDFM-11121 | Long-Term Disability Claim Statement - APS |
| GLTDFM-11120 | Long-Term Disability Claim Statement - Employee |
| GLTDFM-11119 | Long-Term Disability Claim Statement - Employer |
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|
Miscellaneous
|
|
| GGFM-9095 | Consumer Access Request for CA |
| GGFM-9096 | Consumer Deletion Request for CA |
| GLGLFM-9637 | CCPA Privacy Policy and Notice for CA Residents |
| GCIFM-7261 | Wellness / Cancer Screening |
| GLGLFM-9637 SP | CCPA Privacy Policy and Notice for CA Residents - Spanish |
| GLGLFM-7903 | Authorization (Complies with HIPAA) |
| GCIFM-7398 | Supplemental Claim Statement |
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|
Premium/Billing
|
|
| GLFM-5149 | Premium Statement for Step-Rates |
| GMPFM-1512 | Summary Statement |
| GSLFM-1519 | Stop-Loss Summary Statement |
| XGR/1457 | List Billing Change Form |
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|
Short Term Disability
|
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| GDIFM-9683 | Disability Claim - Behavioral Health Treating Provider Stmt |
| GDIFM-8705 | Disability Transition Claim |
| GGFM-3803 | Disability Direct Deposit Authorization |
| GSTDFM-2718 | STD Telephonic Claim HIPAA Authorization |
| GDIFM-8649 | Reimbursement Agreement |
| GDIFM-8650 | Third Party Authorization |
| GVSTDFM-3368 | Portable Voluntary STD Claim Statement |
| XGR/2837 | Short Term Disability Provider Questionnaire (SLOC) |
| GSTDBCH-3229 | Voluntary STD Portability Kit |
| XGR/2839 | Short Term Disability Provider Update Questionnaire (SLOC) |
| GSTDFM-7202 | Short Term Disability Claimant Questionnaire (SLOC) |
| GVSTDPK-4210 | Voluntary STD Portability Kit |
| GMPAP-3430 | Voluntary Portability Application |
| GMPFM-2690 | Voluntary Portability Notice |
| GMPAP-3430 (CA) | Voluntary Portability Application (CA) |
| GLTDFM-5418 | Look-Back Percentage Form |
| GMPAP-3430 (DC) | Voluntary Portability Application (DC) |
| GDIFM-8916 | W-2 Tax Reporting Service Agreement |
| GMPAP-3430 (FL) | Voluntary Portability Application (FL) |
| GMPAP-3430 (GA) | Voluntary Portability Application (GA) |
| GMPAP-3430 (ID) | Voluntary Portability Application (ID) |
| GMPAP-3430 (MD) | Voluntary Portability Application (MD) |
| GMPAP-3430 (ME) | Voluntary Portability Application (ME) |
| GMPAP-3430 (MT) | Voluntary Portability Application (MT) |
| GMPAP-3430 (NJ) | Voluntary Portability Application (NJ) |
| GMPAP-3430 (PA) | Voluntary Portability Application (PA) |
| GMPAP-3430 (UT) | Voluntary Portability Application (UT) |
| GMPAP-3430 (VA) | Voluntary Portability Application (VA) |
| GSTDFM-9852 (CT) | CT PFML Employee Claim Statement |
| GDIFM-10426 | ER FICA Match with W-2 Tax Reporting Service Agreement |
| GSTDFM-9852 (MA) | MA PFML Employee Claim Statement |
| GSTDFM-10784 | PFML Care for Injured Service Member |
| GSTDFM-9857 | PFML Care of Family Member Claim Stmt (CT, MA, WA) |
| GSTDFM-9851 | PFML Employer Claim Statement |
| GSTDFM-9859 | PFML Integrated Disability and Own Serious Health Conditi |
| GSTDFM-9860 | PFML Military Leave/Care of a Covered Service Member |
| GSTDFM-9858 | PFML Own Serious Health Certification (CT, MA, WA) |
| GSTDFM-11118 | Short-Term Disability Claim Statement - APS |
| GSTDFM-11117 | Short-Term Disability Claim Statement - Employee |
| GSTDFM-11116 | Short-Term Disability Claim Statement - Employer |
| GSTDFM-9852 (WA) | WA PFML Employee Claim Statement |
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State Guaranty Notices
|
|
| PA_STATE_GUARANTY | Employer Notice Pennsylvania State Guaranty |
| SC_STATE_GUARANTY | Employer Notice S CAROLINA State Guaranty |
| XGR/2130 | Employer Notice - ALASKA State Guaranty |
| XGR/2131 | Employer Notice ARKANSAS State Guaranty |
| XGR/2132 | Employer Notice CALIFORNIA State Guaranty |
| XGR/2133 | Employer Notice COLORADO State Guaranty |
| XGR/2134 | Employer Notice District of Columbia State Guaranty |
| XGR/2135 | Employer Notice HAWAII State Guaranty |
| XGR/2136 | Employer Notice ILLINOIS State Guaranty |
| GGFM-3613 | Employer Notice INDIANA State Guaranty |
| IA_Gan_2021 | Employer Notice - IOWA State Guaranty |
| XGR/2137 | Employer Notice KANSAS State Guaranty |
| XGR/2138 | Employer Notice LOUISIANA State Guaranty |
| XGR/2139 | Employer Notice MARYLAND State Guaranty |
| XGR/2140 | Employer Notice MINNESOTA State Guaranty |
| XGR/2141 | Employer Notice MISSOURI State Guaranty |
| XGR/2142 | Employer Notice MISSISSIPPI State Guaranty |
| XGR/2143 | Employer Notice MONTANA State Guaranty |
| XGR/2144 | Employer Notice N CAROLINA State Guaranty |
| XGR/2145 | Employer Notice N DAKOTA State Guaranty |
| XGR/2146 | Employer Notice NEW HAMPSHIRE State Guaranty |
| XGR/2147 | Employer Notice NEW JERSEY State Guaranty |
| GGFM-5997 | Employer Notice NEW MEXICO State Guaranty |
| XGR/2148 | Employer Notice NEVADA State Guaranty |
| XGR/2149 | Employer Notice OHIO State Guaranty |
| XGR/2150 | Employer Notice OKLAHOMA State Guaranty |
| XGR/2151 | Employer Notice RHODE ISLAND State Guaranty |
| XGR/2152 | Employer Notice S DAKOTA State Guaranty |
| XGR/2153 | Employer Notice TENNESSEE State Guaranty |
| XGR/2154 | Employer Notice TEXAS State Guaranty |
| XGR/2155 | Employer Notice UTAH State Guaranty |
| XGR/3038 | Employer Notice VA State Guaranty - Must attach to policy |
| GGFM-5998 | Employer Notice WASHINGTON State Guaranty |
| XGR/2156 | Employer Notice WEST VIRGINIA State Guaranty |
| XGR/2157 | Employer Notice WYOMING State Guaranty |
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|
Stop-Loss
|
|
| GSLFM-4575 | Stop-Loss Advance Funding Request Form |
| 2012SLPolicySLOC | 2012 Stop-Loss Policy Sample SLOC |
| XGR/467 | Aggregate Monthly Claims Report |
| GSLFM-4785 | Specific Stop-Loss Claim/50% Notice |
| XGR/1348 | Stop-Loss Simultaneous Reimbursement Request Form |
| GSLFM-4786 | Stop-Loss Direct Deposit Authorization |
| GSLFM-11115 | Stop-Loss Actively-At-Work |
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|
SunAdvisor®
|
|
| SA_HIPAA-PIN | SunAdvisor® HIPAA & Privacy Information Notice - Employee |
| GDIFM-9683 | Disability Claim - Behavioral Health Treating Provider Stmt |
| GSTDFM-6371 | Service Agmt-Full Service Advice to Pay with Benefit Calc |
| GSTDFM-3811 | Service Agreement for Full Service Advice to Pay |
| GSTDFM-5524 | Service Agreement for Advice Plus |
| GSTDFM-11118 | Short-Term Disability Claim Statement - APS |
| GSTDFM-11117 | Short-Term Disability Claim Statement - Employee |
| GSTDFM-11117 (NY) | Short-Term Disability Claim Statement - Employee (NY) |
| GSTDFM-11116 | Short-Term Disability Claim Statement - Employer |
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