Form download and instructions
The Forms Index below allows you to quickly download and print commonly used forms. The forms with a 
icon provide fillable fields that you can complete online. To find more information and instructions about a particular form, click on the 'View instructions' link provided.
Administrative forms | Claim forms | HIPAA forms | Educator Benefits Solutions® forms | Miscellaneous forms
Administrative forms
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Applications |
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Employee Application |
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Arkansas | California | Colorado | Connecticut | District of Columbia | Kansas | Louisiana | Maryland | Missouri | New Hampshire | New Jersey | New York | North Carolina | North Dakota | Oregon | Virginia | All Other States |
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Employee Dental Application |
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Administrative forms – Dental |
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Request to Elect Dental COBRA |
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Employee Election Form - California COBRA |
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Employer Notice of Qualifying Event - California COBRA |
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Notice to Employees/Dependents Affected by Federal Continuance Law |
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Notice of COBRA and ERISA Instructions |
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Administrative forms – Insured Vision |
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Request to Elect Vision COBRA |
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Beneficiary Designation |
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Beneficiary Tips |
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Notice of Conversion Privilege |
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California | Colorado | Connecticut | Florida | Iowa | Kentucky | Louisiana | Michigan | Minnesota | Mississippi | New Hampshire | New York | North Carolina | North Dakota | Oregon | Rhode Island | South Dakota | Texas | Utah | Virginia | Washington | Wisconsin | All Other States |
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Specifics of the Minnesota Life Continuation Privilege |
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Notice of Portability Privilege |
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Portability or Application for LTD Conversion – call 866.909.6065 |
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Facts About Your Conversion Privilege |
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Portability Employee Application for Accident, Cancer or Critical Illness – call 866.909.6065 |
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Notice of Accident Only Portability Privilege |
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Notice of Cancer Only Portability Privilege |
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Notice of Critical Illness Portability Privilege |
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Employee Health Statement for Voluntary and Worksite Coverage |
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All Other States | Arkansas | California | Colorado | Connecticut | District of Columbia| Florida | Illinois | Indiana | Kansas | Kentucky | Louisiana| Maryland | Michigan | Missouri | Montana | New Hampshire | New Jersey | New York |New Mexico | North Carolina | North Dakota | Oregon | Pennsylvania | Rhode Island | South Carolina | South Dakota | Utah | Virginia | West Virginia |
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Faxable Change Document |
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HIV Testing Consent Forms |
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Arizona | Connecticut | District of Columbia | Georgia | Iowa | Kentucky | Maine | Massachusetts | Missouri | New Hampshire | North Dakota | Ohio | Oregon | Texas | Utah | Vermont | West Virginia |
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Request to Elect Critical Illness COBRA (AS) |
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Request to Elect Cancer COBRA (AS) |
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Request to Elect Group Hospital Indemnity GAP COBRA(AS) |
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Statement of Loss of Dental Coverage Due to Life Event |
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Voluntary/Worksite Benefits Service Request (AS) |
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Our forms are available in Portable Document Format (PDF). To view the forms, you may need to download the latest version of Adobe® Acrobat® Reader available at Claims forms
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Dental |
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Dental Claim Statement |
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New York | All Other States |
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Life Insurance Claim Statement |
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Accelerated Benefit Claim Statement–Insured/Spouse |
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Accidental Dismemberment Claim Statement |
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ProviderFund Supplemental Agreement |
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Surviving Family Claim Statement |
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Disability Claim Statement-Life Insurance |
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Short-term Disability Claim Statement |
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New York | All Other States |
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Long-term Disability Claim Statement |
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New York | All Other States |
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Long-term Disability Claim Statement - Conversion |
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Supplementary Report for Benefits |
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New York State Disability Claim Form |
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Accident Claim Statement |
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Employee Paid Supplement Claim |
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Wellness Screening Claim Statement |
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Cancer Claim Statement |
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Employee Paid Supplemental Claim |
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Cancer Screening Claim Statement |
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Critical Illness Claim Statement |
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Employee Paid Supplement Claim |
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Wellness Screening Claim Statement |
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Hospital Confinement Indemnity “Gap” Claim Statement |
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Hospital Confinement Indemnity “Gap” Claim Statement - Spanish |
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HIPAA forms
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HIPAA Authorization For Release of Protected Health Information |
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HIPAA Authorization For Release of Protected Health Information |
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Instructions and Helpful Hints for Completing the HIPAA Authorization for Release of Protected Health Information |
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Medical Underwriting—HIPAA Authorization for Release of Protected Health Information |
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Request for Accounting of Disclosures of Protected Health Information |
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Request for Confidential and/or Alternative Communications of Protected Health Information |
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Request for Restrictions on the Use and Disclosure of Protected Health Information |
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Request to Access, Inspect or Copy Protected Health Information |
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Request to Amend or Correct Protected Health Information |
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Educator Benefits Solutions® forms
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Employer Master Application |
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New Business Transmittal |
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Employee Application |
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Portability Application |
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Disability Claim Form |
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Marketing Materials Request |
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Miscellaneous forms
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Group Insurance Preliminary Application |
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Florida | Kentucky | Maryland | Missouri | New Hampshire (Life, Short-Term Disability, Long-Term Disability, Cancer, Critical Illness, Accident) | New Hampshire (Dental, Vision) | New Jersey | New York | North Carolina | Utah | Virginia | All Other States |
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Third Party Administrator's Statement |
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Life Conversion (Maine & Connecticut) | Group Policies (Maine) |
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