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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.

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Accident Insurance and Accident Disability Insurance
Description Form Number
Accident Claim Statement (H2) GVACFM-7259
Wellness / Cancer Screening GCIFM-7261
Accident Portability Kit GVACPK-3542
Accident Portability Claim Statement GVACFM-4165
Accident Continuation Kit GVACPK-4179
Supplemental Claim Statement GCIFM-7398
Voluntary Portability Application GMPAP-3430
Voluntary Portability Application (CA) GMPAP-3430 (CA)
Voluntary Portability Notice GMPFM-2690
Voluntary Portability Application (DC) GMPAP-3430 (DC)
Voluntary Portability Application (GA) GMPAP-3430 (GA)
Voluntary Portability Application (ID) GMPAP-3430 (ID)
Voluntary Portability Application (MD) GMPAP-3430 (MD)
Voluntary Portability Application (ME) GMPAP-3430 (ME)
Voluntary Portability Application (MT) GMPAP-3430 (MT)
Voluntary Portability Application (NJ) GMPAP-3430 (NJ)
Voluntary Portability Application (PA) GMPAP-3430 (PA)
Voluntary Portability Application (UT) GMPAP-3430 (UT)
Voluntary Portability Application (VA) GMPAP-3430 (VA)
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Cancer
Description Form Number
Cancer Claim Statement GCIFM-7643 Pkt
Cancer Portability Kit GCIPK-7801
Wellness / Cancer Screening GCIFM-7261
Cancer Continuation Kit GCIPK-7802
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Critical Illness
Description Form Number
Cancer Claim Statement GCIFM-7643 Pkt
Critical Illness Employee Packet GCIFM-2831 PKT
Critical Illness HSA Continuation Kit GCIPK-4011
Critical Illness Attending Physician Statement GCIFM-2830
Critical Illness Claim Packet (H2) GCIFM-7258 Pkt
Cancer Portability Kit GCIPK-7801
Wellness / Cancer Screening GCIFM-7261
Cancer Continuation Kit GCIPK-7802
Supplemental Claim Statement GCIFM-7398
Voluntary Portability Application GMPAP-3430
Voluntary Portability Application (CA) GMPAP-3430 (CA)
Voluntary Portability Notice GMPFM-2690
Voluntary Portability Application (DC) GMPAP-3430 (DC)
Critical Illness HSA Portability Kit GCIPK-3537
Critical Illness Portability - Employee Statement GCIFM-4132 Pkt
Voluntary Portability Application (GA) GMPAP-3430 (GA)
Critical Illness Portability - Attending Physician Statement GCIFM-4151
Voluntary Portability Application (ID) GMPAP-3430 (ID)
Voluntary Portability Application (MD) GMPAP-3430 (MD)
Voluntary Portability Application (ME) GMPAP-3430 (ME)
Voluntary Portability Application (MT) GMPAP-3430 (MT)
Voluntary Portability Application (NJ) GMPAP-3430 (NJ)
Voluntary Portability Application (PA) GMPAP-3430 (PA)
Voluntary Portability Application (UT) GMPAP-3430 (UT)
Voluntary Portability Application (VA) GMPAP-3430 (VA)
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Customized Disability
Description Form Number
Customized Disability Employer Statement GVCDFM-3042
Customized Disability Employee Statement GVCDFM-3043 Pkt
Customized Disability Attending Physician Statement GVCDFM-3044
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Dental and Vision
Description Form Number
Dental Claim Statement GDFM-7325
Dental Claim Statement (Prepaid) (NY and non-NY) GDFM-7326
Dental Claim Form - Legacy SLHIC XGR/2262
Vision Request for Reimbursement - VSP VISION_VSP_REIMBURSE
HIPAA Notice of Privacy Practices HIPAA-Notice-Privacy
Vision Request for Reimbursement - VSP - Spanish VISION_VSP_REIMB_SP
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Enrollment
Description Form Number
Outline of Coverage - Disability (2016DI) (NH) OCC_DI_2016DI_NH
Outline of Coverage - STD Only (2016DI) (MT) OCC_STD_2016DI_MT
Refusal of Non-Contributory Coverage GMPFM-2560
Refusal of Non-Contributory Coverage (SLHIC) GMPFM-2560 (SLHIC)
Outline of Coverage - Accident Only (2016) (NH) OCC_AC_2016_NH
Outline of Coverage - LTD Only (2016DI) (MT) OCC_LTD_2016DI_MT
Outline of Coverage - Accident Only (2016) (CA) OCC_AC_2016_CA
Outline of Coverage - Accident Only (2016) (ID) OCC_AC_2016_ID
Outline of Coverage - Accident Only (2016) (MA) OCC_AC_2016_MA
Outline of Coverage - Accident Only (2016) (ME) OCC_AC_2016_ME
Outline of Coverage - Accident Only (2016) (MT) OCC_AC_2016_MT
Outline of Coverage - Accident Only (2016) (NJ) OCC_AC_2016_NJ
Outline of Coverage - Accident Only (2016) (TN) OCC_AC_2016_TN
Outline of Coverage - Accident Only (2016) (UT) OCC_AC_2016 UT
Outline of Coverage - Accident Only (2016) (VT) OCC_AC_2016_VT
Outline of Coverage - Accident Only (2016) (WA) OCC_AC_2016_WA
Outline of Coverage - Cancer Only (2016) (CA) OCC_CAN_2016_CA
Outline of Coverage - Cancer Only (2016) (CT) OCC_CAN_2016_CT
Outline of Coverage - Cancer Only (2016) (ID) OCC_CAN_2016_ID
Outline of Coverage - Cancer Only (2016) (MA) OCC_CAN_2016_MA
Outline of Coverage - Cancer Only (2016) (ME) OCC_CAN_2016_ME
Outline of Coverage - Cancer Only (2016) (MT) OCC_CAN_2016_MT
Outline of Coverage - Cancer Only (2016) (NH) OCC_CAN_2016_NH
Outline of Coverage - Cancer Only (2016) (NJ) OCC_CAN_2016_NJ
Outline of Coverage - Cancer Only (2016) (TN) OCC_CAN_2016_TN
Outline of Coverage - Cancer Only (2016) (UT) OCC_CAN_2016_UT
Outline of Coverage - Cancer Only (2016) (VT) OCC_CAN_2016_VT
Outline of Coverage - Critical Illness Only (2016) (ID) OCC_SD_2016_ID
Outline of Coverage - Critical Illness Only (2016) (MA) OCC_SD_2016_MA
Outline of Coverage - Critical Illness Only (2016) (ME) OCC_SD_2016_ME
Outline of Coverage - Critical Illness Only (2016) (MT) OCC_SD_2016_MT
Outline of Coverage - Critical Illness Only (2016) (NH) OCC_SD_2016_NH
Outline of Coverage - Critical Illness Only (2016) (NJ) OCC_SD_2016_NJ
Outline of Coverage - Critical Illness Only (2016) (TN) OCC_SD_2016_TN
Outline of Coverage - Critical Illness Only (2016) (UT) OCC_SD_2016_UT
Outline of Coverage - Critical Illness Only (2016) (VT) OCC_SD_2016_VT
Outline of Coverage - Hospital Indemnity Only (2016) (CA) OCC_HI_2016_CA
Outline of Coverage - Hospital Indemnity Only (2016) (ID) OCC_HI_2016_ID
Outline of Coverage - Hospital Indemnity Only (2016) (ME) OCC_HI_2016_ME
Outline of Coverage - Hospital Indemnity Only (2016) (MT) OCC_HI_2016_MT
Outline of Coverage - Hospital Indemnity Only (2016) (NH) OCC_HI_2016_NH
Outline of Coverage - Hospital Indemnity Only (2016) (UT) OCC_HI_2016_UT
Outline of Coverage - Hospital Indemnity Only (2016) (VT) OCC_HI_2016_VT
Outline of Coverage - Hospital Indemnity Only (2016) (WA) OCC_HI_2016_WA
Outline of Coverage - LTD Only (2016DI) (VT) OCC_LTD_2016DI_VT
Outline of Coverage - Specified Disease Only (2016) (CA) OCC_SD_2016_CA
Outline of Coverage - STD Only (2016DI) (VT) OCC_STD_2016DI_VT
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Evidence of Insurability
Description Form Number
EOI Application-All states except what's listed individually GMPAP-3040
EOI Application (non-CI) (CA) XGR/1470
EOI application (CT) GMPAP-3040 (CT)
EOI Application (FL) XGR/1467
EOI Application (GA) GMPAP-3040 (GA)
EOI Application (ID) GMPAP-3040 (ID)
EOI Application (IN) GMPAP-3040 (IN)
EOI Application (KS) GMPAP-3040 (KS)
EOI Application (KY) GMPAP-3040 (KY)
EOI Cover Page Instructions GLFM-2055
EOI Application (MA) GMPAP-3040 (MA)
EOI Application (MD) GMPAP-3040 (MD)
EOI Application (ME) - SLOC GMPAP-3040 (ME) - SLOC
EOI Application (ME) - SLHIC GMPAP-3040 (ME) - SLHIC
EOI Application (MN) GMPAP-3040 (MN)
EOI Application (MT) GMPAP-3040 (MT)
EOI Application (NE) GMPAP-3040 (NE)
EOI Application (For use in: NH, MO, and UT) XGR/1466
EOI Application (NJ) SLOC GMPAP-3040 (NJ) SLOC
EOI Application (NJ) SLHIC GMPAP-3040 (NJ) SLHIC
EOI Application (NM) GMPAP-3040 (NM)
EOI Application (OH) GMPAP-3040 (OH)
EOI Application (OR) XGR/1472
EOI Application (RI) GMPAP-3040 (RI)
EOI Application (VT) XGR/1497
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Evidence of Insurability - Critical Illness only
Description Form Number
EOI Application - CI (Generic) GVFM-3637 CI
EOI Application - CI (AK) GVFM-3637 CI (AK)
EOI Application - CI (CA) GVFM-3637 CI (CA)
EOI Application - For Use In CO GVMPAP-6099 CI Only
EOI Application - CI (CT) GVFM-3637 CI (CT)
EOI Application - CI (FL) Lg cases GVFM-3637 (FL) Lg
EOI Application - CI (ID) GVFM-3637 CI (ID)
EOI Application - CI (IN) GVFM-3637 CI (IN)
EOI Application - CI (KY) GVFM-3637 CI (KY)
EOI Application - CI (MD) GVFM-3637 CI (MD)
EOI Application - CI (ME) GVFM-3637 CI (ME)
EOI Application - CI (MN) GVFM-3637 CI (MN)
EOI Application - CI (MO) GVFM-3637(MO)
EOI Application - CI (NC) GVFM-3637 CI (NC)
EOI Application - CI (NE) GVFM-3637 CI (NE)
EOI Application - CI (NH) GVFM-3637 (NH)
EOI Application - CI (OH) GVFM-3637 CI (OH)
EOI Application - CI (OR) GVFM-3637 (OR)
EOI Application - CI (RI) GVFM-3637 CI (RI)
EOI Application - CI (UT) GVFM-3637 (UT)
EOI Application - CI (VA) GVFM-3637 CI (VA)
EOI Application - CI (VT) GVFM-3637 CI (VT)
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FMLA
Description Form Number
Mandatory Notice (NJ) - SLHIC (U.S.) XGR/2255
FMLA Care for Family Member Claim GAMSFM-11128
FMLA Care for Injured Service Member Claim GAMSFM-11125
FMLA Care for Injured Veteran Claim GAMSFM-11126
FMLA Military Family Leave - Qualifying Exigency Cert GAMSFM-11124
FMLA Own Serious Health Condition Certification GAMSFM-11127
FMLA Own Serious Health Condition with Disability Claim GAMSFM-11129
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GAP
Description Form Number
Hospital Confinement (GAP) Claim Form KC4739FSL / GVFM-8239
Formulario De Reclamacion-El Seguro (GAP) De Indemnizac KC4739FSLS / GVFM-8239-S
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Hospital Indemnity
Description Form Number
Hospital Indemnity Claim (H2) GHIFM-9529 Pkt
Hospital Indemnity Portability Kit HIPK-9923
Hospital Indemnity Continuation Kit HIPK-9924
Hospital Indemnity Claim (NY) GHIFM-9529 (NY)
Online Hospital Indemnity Claim (NY) GHIFM-9529-NY-PM Pkt
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Life and AD&D
Description Form Number
Life Conversion Notice (NY and non-NY) GLFM-9073
Life Conversion and Portability Notice (NY and non-NY) GLFM-9018
Life Conversion / Continuation Notice (NY and non-NY) GLFM-9072
Life Conversion for Waiver of Premium/Portability Transition GLFM-9084
Life Conversion Flyer GLFL-9066
Beneficiary Designation GLFM-1233
Beneficiary Designation - Community Property GLFM-1233-Comm-Prop
Beneficiary Designation - Spanish GLFM-1233-SP
Group Life Claims ADL & Cognitive Impairment Questionnaire GLFM-6846
EOI Cover Page Instructions GLFM-2055
SS90: Continuation Notice (MN) GLFM-5201
SS90 Life Continuation Election form (MN) GLFM-5203
SS90 Life Continuation Kit (MN) GLPK-1254 (MN)
LIFE2015: Life Insurance Portability Kit GLPK-EE-6411 - LF15
Group Death Claim Packet: Claimant Statement GLFM-7551
Group Death Claim Packet: Employer Statement GLFM-7552
Group Life Benefits Claim Packet - Employer GLFM-7791
Voluntary Portability Notice GMPFM-2690
Group Life Benefits Claim Packet - Attending Physician GLFM-7793
Group Life Benefits Claim Packet - Employee GLFM-7792
2015 Life Continuation - MN State Election and Notice GLFM-9506 (MN)
2015 Life Continuation Kit GLPK-EE-8150
2015 Life Continuation Kit (MN) GLPK-EE-8151
Death Benefit Claim Authorization GLFM-9596
Life Direct Deposit Authorization GLFM-9297
SS90 Life Continuation Kit GLPK-EE-8149
SS90-New: Life Insurance Portability Kit (Post 2007) GLPK-EE-7162
SS90-Old: Life Insurance Portability Kit (Pre 2007) GLPK-EE-7163
Third Party Authorization - Group Life Benefits GLFM-11158
Third Party Authorization - Group Life Benefits (NY) GLFM-11158 (NY)
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Long Term Disability
Description Form Number
ER FICA Match with W-2 Tax Reporting Service Agreement GDIFM-10426
Long-Term Disability Claim Statement - Employer GLTDFM-11119
Long-Term Disability Claim Statement - Employee GLTDFM-11120
Long-Term Disability Claim Statement - APS GLTDFM-11121
Disability Claim - Behavioral Health Treating Provider Stmt GDIFM-9632
Disability Transition Claim GDIFM-8705
Disability Direct Deposit Authorization GGFM-3803
Reimbursement Agreement GDIFM-8649
Social Security / Retirement Status GLTDFM-3085
Third Party Authorization GDIFM-8650
LTD Conversion Notice GLTDFM-4275
Personal Profile Summary GLTDFM-5441
SLOC LTD Activities of Daily Living Questionnaire GLTDFM-5007 (SLOC)
SLHIC-NY LTD Activities of Daily Living Questionnaire GLTDFM-5007 (SLHIC-NY)
Info Request: Training/Education XGR/1143
LTD Conversion Application XGR/464
Voluntary Portability Notice GMPFM-2690
Look-Back Percentage Form GLTDFM-5418
W-2 Tax Reporting Service Agreement GDIFM-8916
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Miscellaneous
Description Form Number
Consumer Individual Rights Request - CA GLGLFM-11130
Consumer Individual Rights Request (CA) - Spanish GLGLFM-11130 SP
Wellness / Cancer Screening GCIFM-7261
Privacy Policy and Notice for CA Residents GLGLFM-9637
Privacy Policy and Notice for CA Residents - Spanish GLGLFM-9637 SP
Certification of Continued Coverage for a Disabled Dependent GDIFM-11136
Authorization (Complies with HIPAA) GLGLFM-7903
Supplemental Claim Statement GCIFM-7398
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Premium/Billing
Description Form Number
Premium Statement for Step-Rates GLFM-5149
Summary Statement GMPFM-1512
Stop-Loss Summary Statement GSLFM-1519
List Billing Change Form XGR/1457
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Short Term Disability
Description Form Number
ER FICA Match with W-2 Tax Reporting Service Agreement GDIFM-10426
Disability Claim - Behavioral Health Treating Provider Stmt GDIFM-9632
Disability Transition Claim GDIFM-8705
STD Telephonic Claim HIPAA Authorization GSTDFM-2718 Pkt
Disability Direct Deposit Authorization GGFM-3803
Reimbursement Agreement GDIFM-8649
Portable Voluntary STD Claim Statement GVSTDFM-3368 PKT
Short Term Disability Provider Questionnaire (SLOC) XGR/2837
Third Party Authorization GDIFM-8650
Voluntary STD Portability Kit GSTDBCH-3229
Short Term Disability Provider Update Questionnaire (SLOC) XGR/2839
Short Term Disability Claimant Questionnaire (SLOC) GSTDFM-7202
Voluntary STD Continuation Kit GVSTDPK-4210
Voluntary Portability Application GMPAP-3430
Voluntary Portability Application (CA) GMPAP-3430 (CA)
Voluntary Portability Notice GMPFM-2690
Look-Back Percentage Form GLTDFM-5418
Voluntary Portability Application (DC) GMPAP-3430 (DC)
W-2 Tax Reporting Service Agreement GDIFM-8916
Voluntary Portability Application (FL) GMPAP-3430 (FL)
Voluntary Portability Application (GA) GMPAP-3430 (GA)
Voluntary Portability Application (ID) GMPAP-3430 (ID)
Voluntary Portability Application (MD) GMPAP-3430 (MD)
Voluntary Portability Application (ME) GMPAP-3430 (ME)
Voluntary Portability Application (MT) GMPAP-3430 (MT)
Voluntary Portability Application (NJ) GMPAP-3430 (NJ)
Voluntary Portability Application (PA) GMPAP-3430 (PA)
Voluntary Portability Application (UT) GMPAP-3430 (UT)
Voluntary Portability Application (VA) GMPAP-3430 (VA)
CO PFML Employee Claim Statement GSTDFM-9852 (CO)
CT PFML Employee Claim Statement GSTDFM-9852 (CT)
MA PFML Employee Claim Statement GSTDFM-9852 (MA)
OR PFML Employee Claim Statement GSTDFM-9852 (OR)
PFML Care for Injured Service Member GSTDFM-10784
PFML Care of Family Member Claim Stmt (CO, CT, MA, OR, WA) GSTDFM-9857
PFML Employer Claim Statement (CO, CT, MA, OR, WA) GSTDFM-9851
PFML Integrated Disability and Own Serious Health Conditi GSTDFM-9859
PFML Military Leave/Care of a Covered Service Member GSTDFM-9860
PFML Own Serious Health Certification (CO, CT, MA, OR, WA) GSTDFM-9858
PFML Safe Family Violence Leave Certification (CT and OR) GSTDFM-11162
PFML Safe Leave Attestation (CO) GSTDFM-11168
Short-Term Disability Claim Statement - APS GSTDFM-11118
Short-Term Disability Claim Statement - Employee Pkt GSTDFM-11117
Short-Term Disability Claim Statement - Employer GSTDFM-11116
WA PFML Employee Claim Statement GSTDFM-9852 (WA)
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State Guaranty Notices
Description Form Number
Employer Notice Pennsylvania State Guaranty PA_STATE_GUARANTY
Employer Notice S CAROLINA State Guaranty SC_STATE_GUARANTY
Employer Notice - ALASKA State Guaranty XGR/2130
Employer Notice ARKANSAS State Guaranty XGR/2131
Employer Notice CALIFORNIA State Guaranty XGR/2132
Employer Notice COLORADO State Guaranty XGR/2133
Employer Notice District of Columbia State Guaranty XGR/2134
Employer Notice HAWAII State Guaranty XGR/2135
Employer Notice ILLINOIS State Guaranty XGR/2136
Employer Notice INDIANA State Guaranty GGFM-3613
Employer Notice - IOWA State Guaranty IA_Gan_2021
Employer Notice KANSAS State Guaranty XGR/2137
Employer Notice LOUISIANA State Guaranty XGR/2138
Employer Notice MARYLAND State Guaranty XGR/2139
Employer Notice MINNESOTA State Guaranty XGR/2140
Employer Notice MISSOURI State Guaranty XGR/2141
Employer Notice MISSISSIPPI State Guaranty XGR/2142
Employer Notice MONTANA State Guaranty XGR/2143
Employer Notice N CAROLINA State Guaranty XGR/2144
Employer Notice N DAKOTA State Guaranty XGR/2145
Employer Notice NEW HAMPSHIRE State Guaranty XGR/2146
Employer Notice NEW JERSEY State Guaranty XGR/2147
Employer Notice NEW MEXICO State Guaranty GGFM-5997
Employer Notice NEVADA State Guaranty XGR/2148
Employer Notice OHIO State Guaranty XGR/2149
Employer Notice OKLAHOMA State Guaranty XGR/2150
Employer Notice RHODE ISLAND State Guaranty XGR/2151
Employer Notice S DAKOTA State Guaranty XGR/2152
Employer Notice TENNESSEE State Guaranty XGR/2153
Employer Notice TEXAS State Guaranty XGR/2154
Employer Notice UTAH State Guaranty XGR/2155
Employer Notice VA State Guaranty - Must attach to policy XGR/3038
Employer Notice WASHINGTON State Guaranty GGFM-5998
Employer Notice WEST VIRGINIA State Guaranty XGR/2156
Employer Notice WYOMING State Guaranty XGR/2157
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Stop-Loss
Description Form Number
Stop-Loss Advance Funding Request Form GSLFM-4575
2012 Stop-Loss Policy Sample SLOC 2012SLPolicySLOC
Aggregate Monthly Claims Report XGR/467
Specific Stop-Loss Claim/50% Notice GSLFM-4785
Stop-Loss Simultaneous Reimbursement Request Form XGR/1348
Stop-Loss Direct Deposit Authorization GSLFM-4786
Stop-Loss Actively-At-Work GSLFM-11115
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SunAdvisor®
Description Form Number
Service Agmt-Full Service Advice to Pay with Benefit Calc GSTDFM-6371
Disability Claim - Behavioral Health Treating Provider Stmt GDIFM-9632
Service Agreement for Full Service Advice to Pay GSTDFM-3811
Service Agreement for Advice Plus GSTDFM-5524
SunAdvisor Claim Statement - Attending Physician GSTDFM-11152
SunAdvisor Claim Statement - Employer GSTDFM-11151
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