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Find a form
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 |
|
Dental | Alliance network
|
|
| UC-Dep_1208 | Dependent Certification |
| HIPAA-Notice-Privacy | HIPAA Notice of Privacy Practices |
| GDFM-1280 | Request and Authorization for Disclosure of Health Info |
| GDFM-1370 | Dental Claim form with Alliance network |
| GDFM-1370 (AZ) | AZ Dental Claim form with Alliance network |
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|
Dental and Vision | All other networks
|
|
| XGR/2262 | Dental Claim Form |
| HIPAA-Notice-Privacy | HIPAA Notice of Privacy Practices |
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|
SunAdvisor®
|
|
| GSTDFM-6185 | SunAdvisor® Claim Packet - HIPAA and Privacy |
| 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-6168 | SunAdvisor Claim Packet - Attending Physician |
| GSTDFM-6167 | SunAdvisor Claim Packet - Employer |
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|
Enrollment
|
|
| 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
|
|
| GMPAP-3040 | EOI Application (All states except what's list 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) |
| XGR/1476 | EOI Application (MA) - Life Only |
| GMPAP-3040 (MA) Health Only | EOI Application (MA) Health Only |
| GMPAP-3040 (MD) | EOI Application (MD) |
| GLFM-2055 | EOI Cover Page Instructions |
| 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
|
|
| GVFM-3637 CI | EOI Application - CI (Generic) |
| GVFM-3637 CI (AK) | EOI Application - CI (AK) |
| GVFM-3637 CI (CA) | EOI Application - CI (CA) |
| GVFM-3637(CO) | EOI Application - CI (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
|
|
| XGR/2255 | Mandatory Notice (NJ) - SLHIC (U.S.) |
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|
Long Term Disability
|
|
| XGR/1640 | Long Term Disability Claim - Employer's Statement |
| XGR/1641 | Long Term Disability Claim - Employee's Statement |
| XGR/1642 | Long Term Disability Claim - Attending Physician's Statement |
| XGR/1640 (SLHIC) | Long Term Disability Claim - Employer's Statement (SLHIC) |
| GLTDFM-3085 | Social Security / Retirement Status |
| XGR/1641 (SLHIC) | Long Term Disability Claim - Employee's Statement (SLHIC) |
| XGR/1642 - SLHIC | SLHIC (U.S.) Attending Physician Statement |
| GLTDFM-5418 | Look-Back Percentage Form |
| GLTDFM-5441 | Personal Profile Summary |
| GLTDFM-5007 (SLOC) | SLOC LTD Activities of Daily Living Questionnaire |
| GLTDFM-5007 (SLHIC) | SLHIC LTD Activities of Daily Living Questionnaire |
| GLTDFM-4275 | LTD Conversion Notice |
| XGR/464 | LTD Conversion Application |
| GMPFM-2690 | Voluntary Portability Notice |
| XGR/1143 | Info Request: Training/Education |
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|
Life and AD&D
|
|
| GLFM-5464 | Life Conversion for Waiver of Premium/Portability Transition |
| GLFM-5201 | Continuation Notice (MN) |
| GLFM-5203 | Continuation Election form (MN) |
| GR/2664 (MN) | Continuation Kit (MN) |
| GLFM-1233-Comm-Prop | Beneficiary Designation - Community Property |
| GLFM-1233 | Beneficiary Designation |
| XGR/2361 | Group Death Claim Packet |
| GLFM-4147 | Life Conversion Only Notice (NY and non-NY) |
| GLPK-EE-164 | Life insurance conversion: Solutions for employees |
| GLFM-1635 | Conversion and Portability Notice (NY and non-NY) |
| GLFM-4895 | Life Conversion / Continuation Notice (NY and non-NY) |
| XGR/1548 | Group Life Benefits Claim Packet |
| GLFM-2055 | EOI Cover Page Instructions |
| GMPFM-2690 | Voluntary Portability Notice |
| GLFM-6846 | Group Life Claims ADL & Cognitive Impairment Questionnaire |
| GLFM-6846 SLHIC (NY) | SLHIC NY Group Life Claims ADL & Cognitive Impairment Form |
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|
Miscellaneous
|
|
| GGFM-5997 | Employer Notice NEW MEXICO State Guaranty |
| GDFM-1280 | Request and Authorization for Disclosure of Health Info |
| GCIFM-2939 | Wellness Benefit Reimbursement |
| GGFM-5998 | Employer Notice WASHINGTON State Guaranty |
| XGR/1385 | Authorization (Complies with HIPAA) |
| XGR/2694 | Privacy Notice SLOC |
| XGR/2818 | Group W-2 Tax Reporting Sevice Agreement |
| GGFM-3613 | Employer Notice INDIANA State Guaranty |
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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
|
|
| GSTDFM-5298 | Short Term Disability Claim - Employer Statement |
| GSTDFM-5299 | Short Term Disability Claim - Employee Statement |
| GSTDFM-5300 | Short Term Disability Claim - Attending Physician Statement |
| GSTDFM-5330 | STD Reimbursement Agreement |
| GSTDFM-2718 | STD Telephonic Claim HIPAA Authorization |
| GVSTDFM-3368 | Portable Voluntary STD Claim Statement |
| GLTDFM-5418 | Look-Back Percentage Form |
| GMPAP-3430 | Voluntary Portability Application |
| GMPAP-3430 (CA) | Voluntary Portability Application (CA) |
| GMPAP-3430 (GA) | Voluntary Portability Application (GA) |
| GMPAP-3430 (ID) | Voluntary Portability Application (ID) |
| GMPAP-3430 (ME) | Voluntary Portability Application (ME) |
| GMPAP-3430 (NJ) | Voluntary Portability Application (NJ) |
| GMPFM-2690 | Voluntary Portability Notice |
| GSTDBCH-3229 | Voluntary STD Portability Kit |
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|
Customized Disability
|
|
| GVCDFM-3042 | Customized Disability Employer Statement |
| GVCDFM-3043 | Customized Disability Employee Statement |
| GVCDFM-3044 | Customized Disability Attending Physician Statement |
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|
Critical Illness
|
|
| GCIPK-3537 | Critical Illness HSA Portability Kit |
| GCIFM-4132 | Critical Illness Portability - Employee Statement |
| GCIPK-4011 | Critical Illness HSA Continuation Kit |
| GCIFM-2830 | Critical Illness Attending Physician Statement |
| GCIFM-4151 | Critical Illness Portability - Attending Physician Statement |
| GCIFM-2939 | Wellness Benefit Reimbursement |
| GCIFM-2831 | Critical Illness Employee Statement |
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|
Accident Insurance and Accident Disability Insurance
|
|
| GVACFM-3700 | Accident Claim Statement |
| GVACFM-4165 | Accident Portability Claim Statement |
| GVACPK-3542 | Accident Portability Kit |
| GVACPK-4179 | Accident Continuation Kit |
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|
Stop-Loss
|
|
| GSLFM-4575 | Stop-Loss Advance Funding Request Form |
| XGR/467 | Aggregate Monthly Claims Report |
| GSLFM-4785 | Specific Stop-Loss Claim/50% Notice |
| 2012SLPolicySLOC | 2012 Stop-Loss Policy Sample SLOC |
| XGR/1348 | Stop-Loss Simultaneous Reimbursement Request Form |
| GSLFM-4786 | Stop-Loss Direct Deposit Authorization |
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|
State Guaranty Notices
|
|
| XGR/2130 | Employer Notice - ALASKA State Guaranty |
| GGFM-5997 | Employer Notice NEW MEXICO State Guaranty |
| XGR/2131 | Employer Notice ARKANSAS State Guaranty |
| XGR/2132 | Employer Notice CALIFORNIA State Guaranty |
| GGFM-5998 | Employer Notice WASHINGTON State Guaranty |
| XGR/2133 | Employer Notice COLORADO State Guaranty |
| XGR/2134 | Employer Notice WASHINGTON DC State Guaranty |
| XGR/2135 | Employer Notice HAWAII State Guaranty |
| GGFM-3613 | Employer Notice INDIANA State Guaranty |
| XGR/2136 | Employer Notice ILLINOIS State Guaranty |
| IA_Gan_2012 | Employer Notice - IOWA State Guarantee |
| 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 |
| 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 |
| XGR/2156 | Employer Notice WEST VIRGINIA State Guaranty |
| XGR/2157 | Employer Notice WYOMING State Guaranty |
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