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XYZ CUSTOMER CARE, INC.

 
Case Information
electronic billing
Participant AdministrationClaims InquiryMedical UnderwritingReportsBooklet/ContractAdministration Kits
General InformationAccidental Death and Dismemberment BasicLife - Dependent Basic or SuppLife - Employee Basic or VoluntaryList BillingLong Term DisabilityAdministrative Services Only - Long Term DisabilityCommon Forms
Short Term Disability
Administrative Services Only - Short Term Disability
Reference MaterialsCenter for Ability

Administration Kit

This area allows you to view and print commonly used forms, many of which are interactive. An interactive form can be completed online, printed for signature (if applicable) and then mailed or faxed.

In addition, Spanish versions of some forms are available. Click on the "Spanish Version" link to launch the desired form.


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interactive form
 - interactive form
new or revised form
 - new/revised form within last 90 days
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XYZ CUSTOMER CARE, INC.

 

 

  General Information
    Enrollment
    List Billing
    Overview
    Privacy
    Record Keeping List Bill
    Self Administered Billing
    Submitting Claims - Life & AD&D
    Submitting Claims - STD & LTD
    Table of Contents
    Tax Information
    Termination
  interactive form Enrollment Form (ID-27)
    Enrollment Form (ID-27) - Spanish Version
interactive form Enrollment Form NC (ID-27NC)
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   Accidental Death - Basic
  interactive form Absolute Assignment (GR-10136)
  interactive form Attending Physician's Statement of Disability Fl (LC-6902)
    Request for Extension of Employee Life and ADD Coverage (LC-7334)
  interactive form Group Life and/or ADD Claim for Employee or Dependant Safe Haven (LC-7370-CT) new or revised form
  interactive form Group Life and/or ADD Claim for Employee or Dependant Safe Haven (LC-7370-FL)
  interactive form Group Life and/or ADD Claim for Employee or Dependant (LC-7371-CT)
  interactive form Group Life and/or ADD Claim for Employee or Dependant (LC-7371-FL)
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  Life - Dependent Basic or Supp
interactive form Children with Disabilities Eligibility (GR-10547)
  interactive form Domestic Partner Affidavit (GR-12118)
  interactive form Domestic Partner Declaration of Termination (GR-12119)
  interactive form Group Life and/or ADD Claim for Employee or Dependant Safe Haven (LC-7370-CT) new or revised form
  interactive form Group Life and/or ADD Claim for Employee or Dependant Safe Haven (LC-7370-FL)
  interactive form Group Life and/or ADD Claim for Employee or Dependant (LC-7371-CT)
  interactive form Group Life and/or ADD Claim for Employee or Dependant (LC-7371-FL)
    Release from Active Military Duty (LC-7332)
    Request for Extension of Dependent Coverage (LC-7331)
  interactive form Personal Health Application - All Coverages With Child (PA-9199)
  interactive form Personal Health Application - All Coverages Without Child (PA-9199)
  interactive form Personal Health Application - All Life Coverages With Child (PA-9199)
  interactive form Personal Health Application - All Life Coverages Without Child (PA-9199)
  interactive form Personal Health Application - All Life Coverages with LTD (PA-9199)
  interactive form Personal Health Application - Employee and Spouse Life Coverages with LTD (PA-9199)
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  Life - Employee Basic or Voluntary
  interactive form Absolute Assignment (GR-10136)
  Accelerated Death Benefit Consent - WA (LC-6997WA)
  Accelerated Death Benefit Option Disclosure (LC-6779)
  Accelerated Death Benefit Disclosure - WA (LC-6996WA)
 interactive formAttending Physician's Statement (LC-6902)
 interactive formBeneficiary Designation (GR-11927)
  Beneficiary Designation (GR-11927) - Spanish Version
interactive form Benefit Deduction Service Worksheet FI (LC-7168)
 interactive formClaim for Waiver of Premium/Claim for Total and Permanent Disability (LC-3763)
 interactive formConsent for Payment of Living Benefits (LC-6966)
  Consent for Payment of Living Benefits (LC-6966) - Spanish Version
 interactive formNotice of Conversion (GR-10671)
 interactive formPersonal Health Application - All Coverages With Child (PA-9199)
 interactive formPersonal Health Application - All Coverages Without Child (PA-9199)
 interactive formPersonal Health Application - All Life Coverages With Child (PA-9199)
 interactive formPersonal Health Application - All Life Coverages Without Child (PA-9199)
 interactive formPersonal Health Application - All Life Coverages with LTD (PA-9199)
 interactive formPersonal Health Application - Employee and Spouse Life Coverages with LTD (PA-9199)
 interactive formPersonal Health Application - Employee Only Life Coverages (PA-9199)
 interactive formPersonal Health Application - Employee Life with Disability Income Coverage (PA-9199)
 interactive formPersonal Health Application - Employee Life with LTD Coverage Only (PA-9199)
 interactive formPortability Enrollmentnew or revised form
 interactive formPortability Enrollment NYnew or revised form
 interactive formGroup Life and/or ADD Claim for Employee or Dependant Safe Haven (LC-7370-CT)
 interactive formGroup Life and/or ADD Claim for Employee or Dependant Safe Haven (LC-7370-FL)
 interactive formGroup Life and/or ADD Claim for Employee or Dependant (LC-7371-CT)
 interactive formGroup Life and/or ADD Claim for Employee or Dependant (LC-7371-FL) new or revised form
 interactive formProof of Death Portability Life Insurance (LC-7093)
 interactive formRelease of Assignment (GR-10067)
 interactive formStatement of Claim for Living Benefits Acceleration of Death Benefits (LC-6778)
  Statement of Claim for Living Benefits Acceleration of Death Benefits (LC-6778) - Spanish Version
 interactive formStatement of Claim for Living Benefits Acceleration of Death Benefits - NY (LC-6778NY)
 interactive formStatement of Intent (GR-10978)
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   List Billing
 interactive formPersonnel Change Forms - Additions
 interactive formPersonnel Change Forms - Benefits
 interactive formPersonnel Change Forms - Terminations
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   Long Term Disability
 interactive formApplication for LTD Income Benefits FI (LC-4571)
 interactive formApplication for LTD Income Benefits FI (LC-4571) - Spanish Versionnew or revised form
 interactive formApplication for LTD Income Benefits ASO (LC-6104)
  Attending Physician Statement of Continued Disability FI (LC-7137)
 interactive formAttending Physician Statement of Disability FI (LC-7135)
 interactive formBenefit Deduction Service Worksheet FI (LC-7168)
 interactive formNotice of Conversion (GR-11691)
  Request for Extension of Employee Disability Coverage (LC-7333)
 interactive formApplication for LTD Income Benefits ASO (LC-6104)
  Attending Physician Statement of Continued Disability ASO (LC-7138)
 interactive formAttending Physician Statement of Disability ASO (LC-7136)
 interactive formPersonal Health Application - All Coverages With Child (PA-9199)
 interactive formPersonal Health Application - All Coverages Without Child (PA-9199)
 interactive formPersonal Health Application - All Life Coverages With LTD (PA-9199)
 interactive formPersonal Health Application - Disability Income Coverage (PA-9199)
 interactive formPersonal Health Application - Employee and Spouse Life Coverages with LTD (PA-9199)
 interactive formPersonal Health Application - Employee Life with Disability Income Coverage (PA-9199)
 interactive formPersonal Health Application - Employee Life with LTD Coverage Only (PA-9199)
 interactive formPersonal Health Application - LTD Coverage (PA-9199)
 interactive formAttending Physician Statement of Disability ASO (LC-6902)
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  Other Common Forms
  Attending Physician Statement of Continued Disability FI (LC-7137)
  interactive form Benefit Deduction Service Worksheet FI (LC-7168)
  interactive form

Benefit Deduction Service Worksheet ASO (LC-7169)

    Survivor Income (LC-7092)
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    Short Term Disability
  interactive form Application for STD Income Benefits FI (LC-5180)
  interactive form Application for STD Income Benefits FI (LC-5180) - Spanish Versionnew or revised form
  interactive form Attending Physician Statement of Continued Disability FI (LC-7137)
  interactive form Benefit Deduction Service Worksheet FI (LC-7168)
  interactive form Notice of New Jersey Temporary Disability Benefits Claim (LC-3437)
  interactive form Notice and Proof of Claim for Disability Benefits NY DB 450 (LC-5012)
  interactive form Personal Health Application - All Coverages With Child (PA-9199)
  interactive form Personal Health Application - All Coverages Without Child (PA-9199)
  interactive form Personal Health Application - Disability Income Coverage (PA-9199)
  interactive form Personal Health Application - Employee Life with Disability Income Coverage (PA-9199)
  interactive form Personal Health Application - STD Coverage (PA-9199)
    Request For Extension Of Employee Disability Coverage (LC-7333)
  interactive form Attending Physician Statement of Continued Disability Fl (LC-6902)
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    Short Term Disability - Administrative Services Only
  interactive form Application for STD Income Benefits ASO (LC-6526)
  interactive form Attending Physician Statement of Continued Disability ASO (LC-7138)
  interactive form Benefit Deduction Service Worksheet ASO (LC-7169)
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