HEALTH & ACCIDENT FORMS

Claim Forms

Accident

Medical Accident Claim Form (In English) / (en Español)

Critical Illness or Heart & Stroke

Critical Illness Claim Form

Hospital Indemnity (Affordable Choice, Central Choice,
HI Select, Out-of-Pocket)

Medical Illness Claim Form

Home Health Care (HHC) Forms

Home Health Care Claims Packet

OmniFlex Short-Term Care (HHC) Forms

Prescriptons

Prescription Drug Claim Form

Other Forms

Bank Draft Authorization Form (In English) / (en Español)
Beneficiary Change Form
HIPAA Form (release PHI from provider)
HIPAA Form (release PHI to agent, family member, other 3rd party)
Policy Service Form
Wellness Claim Form

EASY UPLOAD MOBILE APP

The Easy Upload mobile app or the Form Upload tool found on the Client Services site can be used to securely send documents to us regarding a specific Life & Health policy or Annuity contract, even if you aren’t a registered contract/policy holder. Simply click on the Start Uploading button. You will need to know the contract/policy number and the owner’s zip code to use this feature.

FORM CATEGORIES

Annuity

Individual and Worksite

Cancer

Dental, Vision & Hearing

EASY UPLOAD MOBILE APP:

The Easy Upload mobile app or the Easy Form Upload tool found on the Client Services site can be used to securely send documents to us regarding a specific Life & Health policy or Annuity contract, even if you aren’t a registered contract/policy holder. Simply click on the Start Uploading button. You will need to know the contract/policy number and the owner’s zip code to use this feature.