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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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Form Number Description
Dental | Alliance network
UC-Dep_1208 Dependent Certification
GDFM-1370 Dental Claim form with Alliance network
GDFM-1280 Request and Authorization for Disclosure of Health Info
GDFM-1370 (AZ) AZ Dental Claim form with Alliance network
HIPAA-Notice-Privacy HIPAA Notice of Privacy Practices
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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®
XGR/647 SunAdvisor Claim Packet
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Enrollment
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
GGFM-3799 (SLHIC NY) Refusal of Non-Contributory Coverage GGFM-3799 (SLHIC NY)
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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)
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)
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)
GLFM-2247 HIPAA Authorization for Medical Underwriting
GLFM-2055 EOI Cover Page Instructions
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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
GLTDFM-4275 LTD Conversion Notice
XGR/464 LTD Conversion Application
XGR/1641 Long Term Disability Claim - Employee's Statement
GVCDFM-3042 Customized Disability Employer Statement
GVCDFM-3043 Customized Disability Employee Statement
XGR/1642 Long Term Disability Claim - Attending Physician's Statement
GVCDFM-3044 Customized Disability Attending Physician Statement
LOOK-BACK_FORM Look-Back Percentage Form
XGR/1642 (SLHIC) Long Term Disability Claim - Attending Physician (SLHIC)
XGR/1641 (SLHIC) Long Term Disability Claim - Employee's Statement (SLHIC)
XGR/1640 (SLHIC) Long Term Disability Claim - Employer's Statement (SLHIC)
GLTDFM-5007 (SLHIC) SLHIC LTD Activities of Daily Living Questionnaire
GLTDFM-5007 (SLOC) SLOC LTD Activities of Daily Living Questionnaire
GLTDFM-3085 Social Security / Retirement Status
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Life and AD&D
GLFM-1233 Beneficiary Designation
XGR/2361 Group Death Claim Packet
GLFM-1635 Conversion and Portability Notice (NY and non-NY)
GMPFM-2690 Voluntary Portability Notice
GLFM-4147 Life Conversion Only Notice (NY and non-NY)
XGR/1548 Group Life Benefits Claim Packet
GLFM-2055 EOI Cover Page Instructions
GLFM-1233-SP Beneficiary Designation - Spanish
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Miscellaneous
GVACPK-4179 Accident Continuation Kit
GCIFM-2831 Critical Illness Employee Statement
GCIFM-2830 Critical Illness Attending Physician Statement
GDFM-1280 Request and Authorization for Disclosure of Health Info
GCIFM-2939 Wellness Benefit Reimbursement
GVACPK-3542 Accident Portability Kit
XGR/1385 Authorization (Complies with HIPAA)
GCIPK-4011 Critical Illness HSA Continuation Kit
XGR/2694 Privacy Notice SLOC
XGR/2818 Group W-2 Tax Reporting Sevice Agreement
GGFM-3613 Employer Notice INDIANA State Guaranty
GVACFM-3700 Accident Claim Statement
GVACFM-4165 Accident Portability Claim Statement
GCIFM-4151 Critical Illness Portability - Attending Physician Statement
GCIFM-4132 Critical Illness Portability - Employee Statement
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Premium/Billing
GMPFM-1512 Summary Statement
GSLFM-1519 Stop-Loss Summary Statement
XGR/1457 List Billing Change Form
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Short Term Disability
GSTDFM-2718 STD Telephonic Claim HIPAA Authorization
GMPAP-3430 Voluntary Portability Application
GSTDBCH-3229 Voluntary STD Portability Kit
GMPFM-2690 Voluntary Portability Notice
GVCDFM-3042 Customized Disability Employer Statement
GVCDFM-3043 Customized Disability Employee Statement
XGR/2603 Short Term Disability Claim Packet
Disab_Auth_APS STD Employee Stmt Authorization and APS
GVCDFM-3044 Customized Disability Attending Physician Statement
SLF_Auth_APS STD Authorization and APS
LOOK-BACK_FORM Look-Back Percentage Form
GVSTDFM-3368 Portable Voluntary STD Claim Statement
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)
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Stop-Loss
XGR/467 Aggregate Monthly Claims Report
2012SLPolicySLOC 2012 Stop-Loss Policy Sample SLOC
GSLFM-4785 Specific Stop-Loss Claim/50% Notice
XGR/1348 Stop-Loss Simultaneous Reimbursement Request Form
GSLFM-4786 Stop-Loss Direct Deposit Authorization
GSLFM-4575 Stop-Loss Advance Funding Request Form
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State Guaranty Notices
XGR/2130 Employer Notice - ALASKA State Guaranty
XGR/2131 Employer Notice ARKANSAS State Guaranty
XGR/2132 Employer Notice CALIFORNIA State Guaranty
XGR/2133 Employer Notice COLORADO State Guaranty
XGR/2134 Employer Notice WASHINGTON DC State Guaranty
XGR/2135 Employer Notice HAWAII State Guaranty
XGR/2136 Employer Notice ILLINOIS State Guaranty
XGR/2138 Employer Notice LOUISIANA State Guaranty
GGFM-3613 Employer Notice INDIANA State Guaranty
XGR/2137 Employer Notice KANSAS 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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