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:
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Accident Insurance and Accident Disability Insurance
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| Description | Form Number |
| SLHIC-NY Wellness / Cancer Screening (NY) (H2) | GCIFM-7261 (NY) |
| Supplemental Claim Statement (NY) (H2) | GCIFM-7398 (NY) |
| Accident Claim Statement (NY) (H2) | GVACFM-7259 (NY) (H2) Pkt |
| Wellness Benefit Reimbursement - SLHIC NY | GCIFM-2939 SLHIC NY |
| Accident Portability Claim Statement | GVACFM-4165 |
| Accident Continuation Kit | GVACPK-4179 |
| Voluntary Portability Application (NY) | GMPAP-3430 (NY) |
| Accident Portability Kit (NY) | GVACPK-3542 (NY) |
| Voluntary Portability Notice (NY) | GMPFM-2690 (NY) |
| Voluntary Portability Application - No HI (NY) | GMPAP-3430 (NY) NOHI |
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Critical Illness
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| Description | Form Number |
| Critical Illness Employee Packet | GCIFM-2831 (NY) Pkt |
| SLHIC-NY Wellness / Cancer Screening (NY) (H2) | GCIFM-7261 (NY) |
| Critical Illness Attending Physician Statement (NY) | GCIFM-2830 (NY) |
| Supplemental Claim Statement (NY) (H2) | GCIFM-7398 (NY) |
| Wellness Benefit Reimbursement - SLHIC NY | GCIFM-2939 SLHIC NY |
| Voluntary Portability Application (NY) | GMPAP-3430 (NY) |
| Voluntary Portability Notice (NY) | GMPFM-2690 (NY) |
| Specified Disease Claim Packet (NY) (H2) | GCIFM-7258 (NY) (H2) Pkt |
| Specified Disease Portability Kit (NY) | GCIPK-3537 (NY) |
| Voluntary Portability Application - No HI (NY) | GMPAP-3430 (NY) NOHI |
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Dental and Vision
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| 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 (NY) | GDFM-11189 (NY) |
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Enrollment
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| Description | Form Number |
| Refusal of Non-Contributory Coverage GGFM-3799 (SLHIC NY) | GGFM-3799 (SLHIC NY) |
| Beneficiary Designation (SLHIC NY) | GLFM-3702 (SLHIC NY) |
| Beneficiary Designation (SLHIC NY) Spanish | GLFM-3702-SP (SLHIC NY) |
| Outline of Coverage - Accident Only (2016) (NY) | OCC_AC_2016_NY |
| Outline of Coverage - Hospital Indemnity Only (2016) (NY) | OCC_HI_2016_NY |
| Outline of Coverage - Specified Disease 65 more (2016) (NY) | OCC_SD65_2016_NY |
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Evidence of Insurability
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| Description | Form Number |
| EOI Application - CI (NY) | GVFM-3637(SLHIC NY) |
| EOI Cover Page Instructions (NY) | GLFM-2055 (NY) |
| EOI application (NY) | GMPAP-3040 (NY) |
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Long Term Disability
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| Description | Form Number |
| Disability Transition Claim (NY) | GDIFM-8705 (NY) |
| Disability Direct Deposit Authorization (SLHIC NY) | GGFM-3803 (SLHIC NY) |
| Reimbursement Agreement (NY) | GDIFM-8649 (NY) |
| Third Party Authorization (NY) | GDIFM-8650 (NY) |
| Info Request: Training/Education (NY) | XNYGR/1144 (SLHIC NY) |
| Social Security / Retirement Status | GLTDFM-3085 |
| LTD Conversion Application SLHIC (NY) | GLTDAP-3475 SLHIC NY |
| Look-Back Percentage Form (NY) | GLTDFM-5418 SLHIC NY |
| LTD Conversion Notice | GLTDFM-4275 |
| NY W-2 Tax Reporting Service Agreement | GDIFM-8916 NY |
| Dis Claim - Behavioral Health Treating Provider Stmt (NY) | GDIFM-9632 NY |
| Long-Term Disability Claim Statement - APS (NY) | GLTDFM-11121 (NY) |
| Long-Term Disability Claim Statement - Employee (NY) | GLTDFM-11120 (NY) |
| Long-Term Disability Claim Statement - Employer (NY) | GLTDFM-11119 (NY) |
| LTD Conversion Application | GLTDAP-4898 |
| LTD Conversion Application (CA) | GLTDAP-4898 (CA) |
| LTD Conversion Application (KS) | GLTDAP-4898 (KS) |
| LTD Conversion Application (WA) | GLTDAP-4898 (WA) |
| NY ER FICA Match with W-2 Tax Reporting Service Agreement | GDIFM-10426 NY |
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Life and AD&D
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| Description | Form Number |
| Life Conversion Notice (NY and non-NY) | GLFM-9073 |
| SLHIC NY Group Life Benefits Claim Packet - Employer | GLFM-7791 SLHIC (NY) |
| Beneficiary Designation (SLHIC NY) | GLFM-3702 (SLHIC NY) |
| Life Conversion and Portability Notice (NY and non-NY) | GLFM-9018 |
| SLHIC NY Group Life Benefits Claim Packet - Employee | GLFM-7792 (SLHIC NY) |
| Beneficiary Designation (SLHIC NY) Spanish | GLFM-3702-SP (SLHIC NY) |
| SLHICNY Group Life Benefits Claim Packet-Attending Physician | GLFM-7793 (SLHIC NY) |
| Life Conversion for Waiver of Premium/Portability Transition | GLFM-9084 |
| Life Insurance Benefits Claim Statement - Claimant | GLFM-7551 (SLHIC NY) |
| Life Conversion Flyer | GLFL-9066 |
| Life Insurance Benefits Claim Statement - Employer | GLFM-7552 (SLHIC NY) |
| SLHIC NY Group Life Claims ADL & Cognitive Impairment Form | GLFM-6846 SLHIC (NY) |
| EOI Cover Page Instructions (NY) | GLFM-2055 (NY) |
| LIFE2015: Life Insurance Portability Kit | GLPK-EE-6411 - LF15 |
| Voluntary Portability Notice (NY) | GMPFM-2690 (NY) |
| Death Benefit Claim Authorization (NY) | GLFM-9596 NY |
| Life Direct Deposit Authorization (NY) | GLFM-9297 (NY) |
| Third Party Authorization - Group Life Insurance Benefits NY | GLFM-11226 NY |
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Short Term Disability
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| Description | Form Number |
| Disability Transition Claim (NY) | GDIFM-8705 (NY) |
| Disability Direct Deposit Authorization (SLHIC NY) | GGFM-3803 (SLHIC NY) |
| Reimbursement Agreement (NY) | GDIFM-8649 (NY) |
| Third Party Authorization (NY) | GDIFM-8650 (NY) |
| PFL Claim - Care for a family member packet | GSTDFM-7265 (NY) |
| Voluntary Portability Application (NY) | GMPAP-3430 (NY) |
| PFL Claim - Bonding with child packet | GSTDFM-7266 (NY) |
| Look-Back Percentage Form (NY) | GLTDFM-5418 SLHIC NY |
| PFL Claim - Military Duty packet | GSTDFM-7267 (NY) |
| NY W-2 Tax Reporting Service Agreement | GDIFM-8916 NY |
| STD Telephonic Claim HIPAA Authorization (NY) | GSTDFM-2718 (NY) Pkt |
| Portable Voluntary STD Claim Statement (SLHIC NY) | GVSTDFM-3368 (NY) |
| Voluntary Portability Notice (NY) | GMPFM-2690 (NY) |
| DBL Claim Form - SLHIC NY | DB 450 SLHIC NY |
| Dis Claim - Behavioral Health Treating Provider Stmt (NY) | GDIFM-9632 NY |
| NY ER FICA Match with W-2 Tax Reporting Service Agreement | GDIFM-10426 NY |
| Short-Term Disability Claim Statement - APS (NY) | GSTDFM-11118 (NY) |
| Short-Term Disability Claim Statement - Employee Pkt (NY) | GSTDFM-11117 (NY) |
| Short-Term Disability Claim Statement - Employer (NY) | GSTDFM-11116 (NY) |
| Voluntary Portability Application - No HI (NY) | GMPAP-3430 (NY) NOHI |
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SunAdvisor®
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| Description | Form Number |
| Service Agmt-Full Service Advice to Pay w/Benefit Calc (NY) | GSTDFM-6371 (NY) |
| Dis Claim - Behavioral Health Treating Provider Stmt (NY) | GDIFM-9632 NY |
| SLHIC NY Accommodation Request - Pregnancy Pkt | NY_ACCOMM_PREG-PKT |
| SunAdvisor Claim Statement - Attending Physician (NY) | GSTDFM-11152 (NY) |
| SunAdvisor Claim Statement - Employer (NY) | GSTDFM-11151 (NY) |
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Stop-Loss
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| Description | Form Number |
| Specific Stop-Loss Claim/50% Notice (SLHIC NY) | GSLFM-4785 (SLHIC NY) |
| Aggregate Monthly Claims Report (SLHIC NY) | GSLFM-3815 (SLHIC NY) |
| Stop-Loss Direct Deposit Authorization (SLHIC NY) | GSLFM-4786 (SLHIC NY) |
| Stop-Loss Summary Statement (SLHIC NY) | GSLFM-3813 (SLHIC NY) |
| Stop-Loss Actively-At-Work (NY) | GSLFM-11115 (NY) |
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Miscellaneous
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| Description | Form Number |
| SLHIC-NY Wellness / Cancer Screening (NY) (H2) | GCIFM-7261 (NY) |
| Authorization (Complies with HIPAA) GLGLFM-7903 (SLHIC NY) | GLGLFM-7903 (NY) |
| Supplemental Claim Statement (NY) (H2) | GCIFM-7398 (NY) |
| Authorization (Complies with HIPAA) (SLHICNY) - Spanish | GLGLFM-7903 (NY) SP |
| NY Certification - Continued Coverage for Disabled Dependent | GDIFM-11136 NY |
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Premium/Billing
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| Description | Form Number |
| Premium Statement for Step-Rates (NY) | GLFM-5149 (NY) |
| Summary Statement (SLHIC NY) | GVFM-3798 (SLHIC NY) |
| List Billing Change Form (SLHIC NY) | GGFM-3818 (SLHIC NY) |
| Stop-Loss Summary Statement (SLHIC NY) | GSLFM-3813 (SLHIC NY) |
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