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 would like to find a form for:
|
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 Notice | GMPFM-2690 |
| Voluntary Portability Application | GMPAP-3430 |
| Voluntary Portability Application (CA) | GMPAP-3430 (CA) |
| 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) |
| Voluntary Portability Application (AL) | GMPAP-3430 (AL) |
| Voluntary Portability Application (TX) | GMPAP-3430 (TX) |
| Voluntary Portability Application - No HI | GMPAP-3430 NOHI |
| Voluntary Portability Application - No HI (AL) | GMPAP-3430 (AL) NOHI |
| Voluntary Portability Application - No HI (CA) | GMPAP-3430 (CA) NOHI |
| Voluntary Portability Application - No HI (DC) | GMPAP-3430 (DC) NOHI |
| Voluntary Portability Application - No HI (GA) | GMPAP-3430 (GA) NOHI |
| Voluntary Portability Application - No HI (ID) | GMPAP-3430 (ID) NOHI |
| Voluntary Portability Application - No HI (MD) | GMPAP-3430 (MD) NOHI |
| Voluntary Portability Application - No HI (ME) | GMPAP-3430 (ME) NOHI |
| Voluntary Portability Application - No HI (NJ) | GMPAP-3430 (NJ) NOHI |
| Voluntary Portability Application - No HI (PA) | GMPAP-3430 (PA) NOHI |
| Voluntary Portability Application - No HI (TX) | GMPAP-3430 (TX) NOHI |
| Voluntary Portability Application - No HI (VA) | GMPAP-3430 (VA) NOHI |
| Back to top | |
|
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 |
| Voluntary Portability Application | GMPAP-3430 |
| Voluntary Portability Application (CA) | GMPAP-3430 (CA) |
| Voluntary Portability Application (DC) | GMPAP-3430 (DC) |
| Voluntary Portability Application (FL) Cancer Only | 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 (VA) | GMPAP-3430 (VA) |
| Voluntary Portability Application (AL) | GMPAP-3430 (AL) |
| Voluntary Portability Application (TX) | GMPAP-3430 (TX) |
| Voluntary Portability Application - No HI | GMPAP-3430 NOHI |
| Voluntary Portability Application - No HI (AL) | GMPAP-3430 (AL) NOHI |
| Voluntary Portability Application - No HI (CA) | GMPAP-3430 (CA) NOHI |
| Voluntary Portability Application - No HI (DC) | GMPAP-3430 (DC) NOHI |
| Voluntary Portability Application - No HI (GA) | GMPAP-3430 (GA) NOHI |
| Voluntary Portability Application - No HI (ID) | GMPAP-3430 (ID) NOHI |
| Voluntary Portability Application - No HI (MD) | GMPAP-3430 (MD) NOHI |
| Voluntary Portability Application - No HI (ME) | GMPAP-3430 (ME) NOHI |
| Voluntary Portability Application - No HI (TX) | GMPAP-3430 (TX) NOHI |
| Voluntary Portability Application - No HI (VA) | GMPAP-3430 (VA) NOHI |
| Back to top | |
|
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 Notice | GMPFM-2690 |
| Voluntary Portability Application | GMPAP-3430 |
| Voluntary Portability Application (CA) | GMPAP-3430 (CA) |
| 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) |
| Voluntary Portability Application (AL) | GMPAP-3430 (AL) |
| Voluntary Portability Application (TX) | GMPAP-3430 (TX) |
| Voluntary Portability Application - No HI | GMPAP-3430 NOHI |
| Voluntary Portability Application - No HI (AL) | GMPAP-3430 (AL) NOHI |
| Voluntary Portability Application - No HI (CA) | GMPAP-3430 (CA) NOHI |
| Voluntary Portability Application - No HI (DC) | GMPAP-3430 (DC) NOHI |
| Voluntary Portability Application - No HI (GA) | GMPAP-3430 (GA) NOHI |
| Voluntary Portability Application - No HI (ID) | GMPAP-3430 (ID) NOHI |
| Voluntary Portability Application - No HI (MD) | GMPAP-3430 (MD) NOHI |
| Voluntary Portability Application - No HI (ME) | GMPAP-3430 (ME) NOHI |
| Voluntary Portability Application - No HI (NJ) | GMPAP-3430 (NJ) NOHI |
| Voluntary Portability Application - No HI (PA) | GMPAP-3430 (PA) NOHI |
| Voluntary Portability Application - No HI (TX) | GMPAP-3430 (TX) NOHI |
| Voluntary Portability Application - No HI (VA) | GMPAP-3430 (VA) NOHI |
| Back to top | |
|
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 |
| Voluntary Portability Application (CA) | GMPAP-3430 (CA) |
| Voluntary Portability Application (DC) | GMPAP-3430 (DC) |
| Voluntary Portability Application (AL) | GMPAP-3430 (AL) |
| Voluntary Portability Application (TX) | GMPAP-3430 (TX) |
| Voluntary Portability Application - No HI (AL) | GMPAP-3430 (AL) NOHI |
| Voluntary Portability Application - No HI (CA) | GMPAP-3430 (CA) NOHI |
| Voluntary Portability Application - No HI (DC) | GMPAP-3430 (DC) NOHI |
| Voluntary Portability Application - No HI (TX) | GMPAP-3430 (TX) NOHI |
| Back to top | |
|
Dental and Vision
|
|
| Description | Form Number |
| 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 |
| Dental ADA Claim Statement | GDFM-11189 |
| Back to top | |
|
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 - Cancer Only (2016) (WA) | OCC-SD_CAN_2016_WA |
| 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 - Critical Illness Only (2016) (WA) | OCC_SD_2016_WA |
| 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 |
| Back to top | |
|
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 |
| Back to top | |
|
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) |
| Back to top | |
|
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 |
| Back to top | |
|
GAP
|
|
| Description | Form Number |
| Hospital Confinement (GAP) Claim Form | KC4739FSL / GVFM-8239 |
| Formulario De Reclamacion-El Seguro (GAP) De Indemnizac | KC4739FSLS / GVFM-8239-S |
| Back to top | |
|
Hospital Indemnity
|
|
| Description | Form Number |
| Hospital Indemnity Claim (H2) | GHIFM-9529 Pkt |
| Wellness / Cancer Screening | GCIFM-7261 |
| Hospital Indemnity Portability Kit | HIPK-9923 |
| Hospital Indemnity Continuation Kit | HIPK-9924 |
| Voluntary Portability Application | GMPAP-3430 |
| Voluntary Portability Application (CA) | GMPAP-3430 (CA) |
| 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 (NJ) | GMPAP-3430 (NJ) |
| Voluntary Portability Application (PA) | GMPAP-3430 (PA) |
| Voluntary Portability Application (VA) | GMPAP-3430 (VA) |
| Application (FL) - Hospital Indemnity only | GMPAP-3430 (FL) HI |
| Hospital Indemnity Claim (NY) | GHIFM-9529 (NY) |
| Voluntary Portability Application (AL) | GMPAP-3430 (AL) |
| Voluntary Portability Application (TX) | GMPAP-3430 (TX) |
| Back to top | |
|
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 |
| Voluntary Portability Notice | GMPFM-2690 |
| 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 |
| Life Insurance Benefits Claim Statement - Claimant | GLFM-7551 |
| Life Insurance Benefits Claim Statement - Employer | GLFM-7552 |
| Group Life Benefits Claim Packet - Employer | GLFM-7791 |
| 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 |
| Accelerated Benefits Claim Statement - Attending Provider | GLFM-11176 |
| Accelerated Benefits Claim Statement - Attending Provider | GLFM-11176 (NY) |
| Accelerated Benefits Claim Statement - Employee | GLFM-11175 Pkt |
| Accelerated Benefits Claim Statement - Employee | GLFM-11175 (NY) Pkt |
| Death Benefit Claim Authorization | GLFM-9596 |
| Death Benefit Claim Authorization (SLHIC) | GLFM-9596 SLHIC |
| General Release Accelerated Death Benefit | GLFM-11228 |
| General Release Accelerated Death Benefit | GLFM-11228 NY |
| Life Direct Deposit Authorization | GLFM-9297 |
| Life Direct Deposit Authorization (SLHIC) | GLFM-9297 SLHIC |
| 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) |
| Third Party Authorization - Group Life Insurance Benefits | GLFM-11226 |
| Back to top | |
|
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 |
| Voluntary Portability Notice | GMPFM-2690 |
| 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 |
| Look-Back Percentage Form | GLTDFM-5418 |
| W-2 Tax Reporting Service Agreement | GDIFM-8916 |
| Back to top | |
|
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 |
| Back to top | |
|
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 |
| Back to top | |
|
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 |
| Voluntary Portability Notice | GMPFM-2690 |
| 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) |
| 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) Cancer Only | 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) |
| Application (FL) - Hospital Indemnity only | GMPAP-3430 (FL) HI |
| CO PFML Employee Claim Statement | GSTDFM-9852 (CO) |
| CT PFML Employee Claim Statement | GSTDFM-9852 (CT) |
| Family Leave Insurance - Care for Family Member Claim Stmt | GSTDFM-11179 |
| Family Leave Insurance - Employee Claim Statement | GSTDFM-11178 |
| Family Leave Insurance - Employer Claim Statement | GSTDFM-11177 |
| 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 |
| Voluntary Portability Application (AL) | GMPAP-3430 (AL) |
| Voluntary Portability Application (TX) | GMPAP-3430 (TX) |
| Voluntary Portability Application - No HI | GMPAP-3430 NOHI |
| Voluntary Portability Application - No HI (AL) | GMPAP-3430 (AL) NOHI |
| Voluntary Portability Application - No HI (CA) | GMPAP-3430 (CA) NOHI |
| Voluntary Portability Application - No HI (DC) | GMPAP-3430 (DC) NOHI |
| Voluntary Portability Application - No HI (GA) | GMPAP-3430 (GA) NOHI |
| Voluntary Portability Application - No HI (ID) | GMPAP-3430 (ID) NOHI |
| Voluntary Portability Application - No HI (MD) | GMPAP-3430 (MD) NOHI |
| Voluntary Portability Application - No HI (ME) | GMPAP-3430 (ME) NOHI |
| Voluntary Portability Application - No HI (NJ) | GMPAP-3430 (NJ) NOHI |
| Voluntary Portability Application - No HI (PA) | GMPAP-3430 (PA) NOHI |
| Voluntary Portability Application - No HI (TX) | GMPAP-3430 (TX) NOHI |
| Voluntary Portability Application - No HI (VA) | GMPAP-3430 (VA) NOHI |
| WA PFML Employee Claim Statement | GSTDFM-9852 (WA) |
| Back to top | |
|
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_Notice |
| 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 |
| Employer Notice - Vermont State Guaranty | VT_Gan_2024 |
| Back to top | |
|
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 |
| Back to top | |
|
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 |
| SLOC Accommodation Request - Pregnancy Pkt | SLOC_ACCOMM_PREG-PKT |
| SunAdvisor Claim Statement - Attending Physician | GSTDFM-11152 |
| SunAdvisor Claim Statement - Employer | GSTDFM-11151 |
| Back to top | |