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General InformationLife & Disability formsEnrollment FormsGeneral FormsLife FormsLTD FormsLTD & STD formsPortability FormsPremium Waiver FormsSTD formsStop Loss FormsClaimsUnderwritingReference 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.

For New York and New Jersey producers, contact The Business Council of New York State, Inc. for commission, sales and service information regarding accounts written through The Business Council of New York State, Inc. Insurance Fund.

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interactive form
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new or revised form
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    General Information
    Table of Contents
    Overview
    Enrollment
    Self Administered Billing
    List Billing
    Record Keeping List Bill
    Termination
    Tax Information
    Submitting Claims - STD & LTD
    Submitting Claims - Life & AD&D
    Privacy
    Return to Top
    Life and Disability Forms - Enrollment
  interactive form Enrollment Form (ID-27)
    Enrollment Form (ID-27) - Spanish Version
  interactive form Enrollment Form NC (ID-27NC)
  interactive form Personnel Change Forms - Additions
  interactive form Personnel Change Forms - Change in Benefits
  interactive form Personnel Change Forms - Terminations
    Return to Top
    Life and Disability Forms - General
  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 - Disability Income Coverage (PA-9199)
  interactive form Personal Health Application - Employee and Spouse Life Coverages with LTD (PA-9199)
  interactive form Personal Health Application - Employee Only Life Coverages (PA-9199)
  interactive form Personal Health Application - Employee Life with Disability Income Coverage (PA-9199)
  interactive form Personal Health Application - Employee Life with LTD Coverage Only (PA-9199)
  interactive form Personal Health Application - LTD Coverage (PA-9199)
  interactive form Personal Health Application - STD Coverage (PA-9199)
  Return to Top
    Life and Disability Forms - Life
  interactive form Group Life and/or ADD Claim for Employee or Dependant Safe Haven - CT claim office (LC-7370) new or revised form
  interactive form Group Life and/or ADD Claim for Employee or Dependant Safe Haven - FL claim office (LC-7370) new or revised form
  interactive form Group Life and/or ADD Claim for Employee or Dependant - CT claim office (LC-7371)
  interactive form Group Life and/or ADD Claim for Employee or Dependant - FL claim office (LC-7371)
  interactive form Absolute Assignment and Beneficiary Designation Form (GR-10136)
    Accelerated Death Benefit Option Disclosure (LC-6779)
    Accelerated Death Benefit Disclosure - WA (LC-6996WA)
  interactive form Beneficiary Designation (GR-11927)
    Beneficiary Designation (GR-11927) - Spanish Version
  interactive form Children with Disabilities Eligibility (GR-10547)
  interactive form Consent form for Payment of Accelerated Death Benefits (LC-6966)
    Consent form for Payment of Living Benefits (LC-6966) - Spanish Version
  interactive form Domestic Partner Affidavit (GR-12118)
  interactive form Domestic Partner Declaration of Termination (GR-12119)
  interactive form Notice of Conversion Privilege LTD (GR-11691)
  interactive form Notice of Conversion Privilege Life Insurance Only (GR-10671)
  interactive form Proof of Death Portability Life Insurance (LC-7093)
  interactive form Release of Assignment (GR-10067)
    Release from Active Military Duty (LC-7332)
    Request for Extension of Dependent Coverage (LC-7331)
    Request for Extension of Employee Life and ADD Coverage (LC-7334)
  interactive form Statement 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 form Statement of Claim for Living Benefits Acceleration of Death Benefits - NY (LC-6778NY)
  interactive form Statement of Intent (GR-10978)
    Survivor Income (LC-7092)
    Return to Top
    Life and Disabilty Forms - Long Term Disability
  interactive form Application for LTD Income Benefits ASO (LC-6104)
  interactive form Application for LTD Income Benefits FI (LC-4571)
  interactive form Application for LTD Income Benefits FI (LC-4571) - Spanish Versionnew or revised form
  interactive form Attending Physician Statement of Disability ASO (LC-7136)
  interactive form Attending Physician Statement of Disability FI (LC-7135)
  interactive form Notice of Conversion (GR-11691)
    Return to Top
    Life and Disability Forms - LTD and STD
  interactive form Attending Physician Statement of Continued Disability ASO (LC-7138)
  interactive form Attending Physician Statement of Continued Disability FI (LC-7137)
  interactive form Benefit Deduction Service Worksheet ASO (LC-7169)
  interactive form Benefit Deduction Service Worksheet FI (LC-7168)
    Request for Extension of Employee Disability Coverage (LC-7333)
    Return to Top
    Life and Disability Forms - Portability
  interactive form Portability Enrollmentnew or revised form
  interactive form Portability Enrollment NY new or revised form
    Return to Top
    Life and Disability Forms - Premium Waiver
  interactive form Attending Physician Statement of Continued Disability Fl (LC-6902)
  interactive form Claim for Waiver of Premium/Claim for Total and Permanent Disability (LC-3763)
    Return to Top
    Life and Disability Forms - Short Term Disability
  interactive form Application for STD Income Benefits ASO (LC-6526)
  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 Notice and Proof of Claim for Disability Benefits NY DB 450 (LC-5012)
  interactive form Notice of New Jersey Temporary Disability Benefits Claim (LC-3437)
    Request For Extension Of Employee Disability Coverage (LC-7333)
    Return to Top
    Stop Loss Forms - Claims
  interactive form ASL Monthly Claim and Census Report
  interactive form ASL Request for Reimbursement Checklist
  interactive form ISL Medical/High Dollar Notification
  interactive form ISL Reimbursement Request
  interactive form Release of Medical Information
    Return to Top
    Stop Loss Forms - Underwriting
  interactive form Medical Disclosure Statement
    Return to Top
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