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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 |
|
Accident Insurance and Accident Disability Insurance
|
|
| GVACFM-3700 (NY) | Accident Claim Statement (NY) |
| GCIFM-7398 (NY) | Supplemental Claim Statement (NY) (H2) |
| GVACFM-7259 (NY) (H2) | Accident Claim Statement (NY) (H2) |
| GVACPK-3542 | Accident Portability Kit |
| GCIFM-2939 SLHIC NY | Wellness Benefit Reimbursement - SLHIC NY |
| GVACPK-4179 | Accident Continuation Kit |
| GVACFM-4165 | Accident Portability Claim Statement |
| GMPFM-2690 | Voluntary Portability Notice |
| GMPAP-3430 (NY) | Voluntary Portability Application (NY) |
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|
Critical Illness
|
|
| GCIFM-2831 (NY) | Critical Illness Employee Statement (NY) |
| GCIFM-7398 (NY) | Supplemental Claim Statement (NY) (H2) |
| GCIFM-2830 (NY) | Critical Illness Attending Physician Statement (NY) |
| GCIFM-2939 SLHIC NY | Wellness Benefit Reimbursement - SLHIC NY |
| GMPAP-3430 (NY) | Voluntary Portability Application (NY) |
| GCIFM-7258 (NY) (H2) | Critical Illness Claim Statement (NY) (H2) |
| GCIFM-7261 (NY) | SLHIC-NY Wellness / Cancer Screening (NY) (H2) |
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|
Dental and Vision
|
|
| GDFM-7325 (NY) | Dental Claim Statement (NY) |
| GDFM-7326 | Dental Claim Statement (Prepaid) (NY and non-NY) |
| XGR/2262 | Dental Claim Form - Legacy SLHIC |
| HIPAA-Notice-Privacy | HIPAA Notice of Privacy Practices |
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|
Enrollment
|
|
| GGFM-3799 (SLHIC NY) | Refusal of Non-Contributory Coverage GGFM-3799 (SLHIC NY) |
| GLFM-3702 (SLHIC NY) | Beneficiary Designation (SLHIC NY) |
| GLFM-3702-SP (SLHIC NY) | Beneficiary Designation (SLHIC NY) Spanish |
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|
Evidence of Insurability
|
|
| XNYGR/1480 | EOI Application (NY) |
| GVFM-3637(SLHIC NY) | EOI Application - CI (NY) |
| GLFM-2247 SLHIC (NY) | HIPAA Authorization for Medical Underwriting - SLHIC NY |
| GLFM-2055 (NY) | EOI Cover Page Instructions (NY) |
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|
Long Term Disability
|
|
| GDIFM-8643 (NY) LTD | Unified Disability Claim (LTD) (NY) - Employer |
| GDIFM-8644 (NY) LTD | Unified Disability Claim (LTD) (NY) - Employee |
| GDIFM-8645 (NY) LTD | Unified Disability Claim (LTD) (NY) - APS |
| GDIFM-8705 (NY) | Disability Transition Claim (NY) |
| GLTDFM-3085 | Social Security / Retirement Status |
| GGFM-3803 (SLHIC NY) | Direct Deposit Authorization (SLHIC NY) |
| GDIFM-8649 LTD (NY) | Reimbursement Agreement - LTD (NY) |
| GDIFM-8650 LTD (NY) | Third Party Authorization - LTD (NY) |
| XNYGR/1144 (SLHIC NY) | Info Request: Training/Education (NY) |
| GLTDFM-4275 | LTD Conversion Notice |
| GLTDAP-3475 SLHIC NY | LTD Conversion Application SLHIC (NY) |
| GLTDFM-5418 SLHIC NY | Look-Back Percentage Form (NY) |
| GDIFM-8916 NY | NY W-2 Tax Reporting & ER FICA Match with W-2 Reporting |
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|
Life and AD&D
|
|
| GLFM-9073 | Life Conversion Notice (NY and non-NY) |
| GLFM-7791 SLHIC (NY) | SLHIC NY Group Life Benefits Claim Packet - Employer |
| GLFM-9018 | Life Conversion and Portability Notice (NY and non-NY) |
| GLFM-7792 (SLHIC NY) | SLHIC NY Group Life Benefits Claim Packet - Employee |
| GLFM-7793 (SLHIC NY) | SLHICNY Group Life Benefits Claim Packet-Attending Physician |
| GLFM-9084 | Life Conversion for Waiver of Premium/Portability Transition |
| GLFM-7551 (SLHIC NY) | SLHIC NY Death Benefit Packet: Claimant Statement |
| GLFL-9066 | Life Conversion Flyer |
| GLFM-7552 (SLHIC NY) | SLHIC NY Group Death Benefit Claim Packet:Employer Statement |
| GLFM-3702 (SLHIC NY) | Beneficiary Designation (SLHIC NY) |
| GLFM-3702-SP (SLHIC NY) | Beneficiary Designation (SLHIC NY) Spanish |
| GLFM-6846 SLHIC (NY) | SLHIC NY Group Life Claims ADL & Cognitive Impairment Form |
| GLFM-2247 SLHIC (NY) | HIPAA Authorization for Medical Underwriting - SLHIC NY |
| GLFM-2055 (NY) | EOI Cover Page Instructions (NY) |
| GLPK-EE-6411 - LF15 | LIFE2015: Life Insurance Portability Kit |
| GMPFM-2690 (NY) | Voluntary Portability Notice (NY) |
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|
Short Term Disability
|
|
| GDIFM-8643 (NY) STD | Unified Disability Claim (STD) (NY) - Employer |
| GDIFM-8644 (NY) STD | Unified Disability Claim (STD) (NY) - Employee |
| GDIFM-8645 (NY) STD | Unified Disability Claim (STD) (NY) - APS |
| DB 450 | DBL Claim Form - NY |
| GDIFM-8705 (NY) | Disability Transition Claim (NY) |
| HCPS DB 450 | Stand Alone DBL Part B Health Care Provider's Statement - NY |
| GGFM-3803 (SLHIC NY) | Direct Deposit Authorization (SLHIC NY) |
| GSTDFM-7265 (NY) | PFL Claim - Care for a family member packet |
| GSTDFM-7266 (NY) | PFL Claim - Bonding with child packet |
| GSTDFM-7267 (NY) | PFL Claim - Military Duty packet |
| GGFM-3803 (NY) (PFL) | NY PFL - Direct Deposit Authorization |
| GDIFM-8649 STD (NY) | Reimbursement Agreement - STD (NY) |
| GLTDFM-5418 SLHIC NY | Look-Back Percentage Form (NY) |
| GDIFM-8650 STD (NY) | Third Party Authorization - STD (NY) |
| GDIFM-8916 NY | NY W-2 Tax Reporting & ER FICA Match with W-2 Reporting |
| GSTDFM-2718 (NY) | STD Telephonic Claim HIPAA Authorization (NY) |
| GVSTDFM-3368 (NY) | Portable Voluntary STD Claim Statement (SLHIC NY) |
| GMPFM-2690 (NY) | Voluntary Portability Notice (NY) |
| GMPAP-3430 (NY) | Voluntary Portability Application (NY) |
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|
SunAdvisor®
|
|
| GSTDFM-6185 (SLHIC NY) | SunAdvisor® Claim Packet - HIPAA and Privacy (SLHIC NY) |
| GSTDFM-6371 (NY) | Service Agmt-Full Service Advice to Pay w/Benefit Calc (NY) |
| GDIFM-8645 (NY) SA | Unified Disability Claim (SA) (NY) - APS |
| GDIFM-8643 (NY) SA | Unified Disability Claim (SA) (NY) - Employer |
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|
Stop-Loss
|
|
| GSLFM-4785 (SLHIC NY) | Specific Stop-Loss Claim/50% Notice (SLHIC NY) |
| GSLFM-3815 (SLHIC NY) | Aggregate Monthly Claims Report (SLHIC NY) |
| GSLFM-4786 (SLHIC NY) | Stop-Loss Direct Deposit Authorization (SLHIC NY) |
| GSLFM-3813 (SLHIC NY) | Stop-Loss Summary Statement (SLHIC NY) |
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|
Miscellaneous
|
|
| GCIFM-7398 (NY) | Supplemental Claim Statement (NY) (H2) |
| GLGLFM-7903 (NY) | Authorization (Complies with HIPAA) GLGLFM-7903 (SLHIC NY) |
| GGFM-9095 | Consumer Access Request for CA |
| GGFM-9096 | Consumer Deletion Request for CA |
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|
Premium/Billing
|
|
| GLFM-5149 (NY) | Premium Statement for Step-Rates (NY) |
| GVFM-3798 (SLHIC NY) | Summary Statement (SLHIC NY) |
| GGFM-3818 (SLHIC NY) | List Billing Change Form (SLHIC NY) |
| GSLFM-3813 (SLHIC NY) | Stop-Loss Summary Statement (SLHIC NY) |
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