Forms

PLANHOLDER SERVICES FORM

  1. PS-003 – APPLICATION FOR REINSTATEMENT (INDIVIDUAL)
  2. PS-004 – APPLICATION FOR AMENDMENT (INDIVIDUAL)
  3. PS-011 – PLANHOLDER CONTACT INFORMATION FORM (INDIVIDUAL)
  4. AFFIDAVIT OF LOSS – CFP
  5. AFFIDAVIT OF LOSS – PLAN CONTRACT
  6. BENEFIT SETTLEMENT FORM (BSF) FOR INDIVIDUAL PLANS
  7. APPLICATION FOR REINSTATEMENT (GROUP PLANS)
  8. APPLICATION FOR AMENDMENT (GROUP PLANS)
  9. BENEFIT SETTLEMENT FORM (GROUP PLANS)
  10. AUTHORITY TO DEPOSIT (GROUP PLANS)
  11. REISSUANCE AND REPLACEMENT OF CHECKS REQUEST FORM
  12. DEATH CLAIMS REQUIREMENT
  13. DISABILITY DISMEMBERMENT CLAIMS REQUIREMENTS
  14. AUTHORITY TO DEPOSIT – BENEFICIARY (DEATH CLAIM)
  15. CLAIMANT STATEMENT FORM – DEATH CLAIM
  16. ATTENDING PHYSICIAN’S STATEMENT – DEATH CLAIM
  17. CLAIMANT STATEMENT FORM – TOTAL DISABILITY CLAIM
  18. ATTENDING PHYSICIAN’S STATEMENT – TOTAL DISABILITY
  19. LIST OF ACCREDITED SERVICING MORTUARIES
  20. AUTHORITY TO DEPOSIT (ATD) FOR NOMINEE/BENEFICIARY
  21. AUTHORITY TO DEPOSIT (ATD) FOR LEGAL GUARDIAN