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USAble Life
Claim Forms
- Authorization for Release of Medical Records
- Accelerated Death Benefit
- Accidental Death and Dismemberment
- Conversion
- Life
- LTD - Please call USAble Customer Service at 1-800-370-5856.
- STD
- Waiver of Premium
(HIPAA regulations; must be submitted with all claim forms)
Application Forms
- Evidence of Insurability Form
- Application (Group products Basic & Voluntary)
- Application Group LTD
- Application Trust Group Life/AD&D/Dependent Life/STD
- Group Apply (Group combined Health and Life)
- Application Trust Group LTD
- Application Voluntary Group Life Participation Agreement
- W-2 Agreement
- Waiver of Premium
Enrollment Forms
Miscellaneous Forms
- Beneficiary Change Form
- Continuation of Voluntary Group Term Live
- Claim Form Appointment of Authorized Representative
- Conversion for Group Life
- Claim Form STD Update
- Employee Payroll Deduction Form
(for employees whose employer has selected the portability provision)
ACS - Dental administration
Fort Dearborn Life
- Application - Combined/Basic Products
- Benefits Manager Registration Form
- Claim Form - All other coverages (Including STD)
- Claim Form - LTD
- Conversion Application
- Disclosure Statement (Distributed with all EOI forms)
- EAP Account Notice - GuidanceResources Online
- Employee Enrollment/Change Form
- Evidence of Insurability
- Guide to Claims
- Guide to List Billing
- Guide to Self-Administration
- Guide to Web Billing
- New Case Issue Transmittal
- Notice of Information Practices (Must be distributed with all EOI forms)
- Policy Holder Change Form (PHC1)
- Portability Application
- W-2 Agreement
SDSA - Flexible benefit plan administration