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USAble Life

Claim Forms

• Accelerated Death Benefit
• Accidental Death and Dismemberment (AD&D)
• Life - Proof of Death
• LTD - Please call USAble Customer Service at 1-800-370-5856.
• Short Term Disability Income Benefits (paper submission)
• Short Term Disability Income Benefits (telephonic submission)
• Waiver of Premium - Application for Extended Insurance Benefits

Application Forms

• Evidence of Insurability
• Application Trust Group Life/AD&D/Dependent Life/STD
• Application for BCBSNC Coverage (Group combined Health and Life)
• Application Trust Group LTD
• W-2 Agreement
• Application (Group Products, Basic and Voluntary)

Enrollment Forms

• Group Enrollment or Change form
• Enrollment Voluntary Products
• Enrollment Voluntary STD
• Enrollment and Change Application with health questions (1-24 employees)
• Spanish Enrollment and Change Application with health questions (1-24 employees)
• Enrollment and Change Application (25+ employees)
• Spanish Enrollment and Change Application (25+ employees)

Miscellaneous Forms

• Beneficiary Change Form
• Continuation of Voluntary Group Term Life

(for employees whose employer has selected the portability provision)
• Appointment of Authorized Representative
• Conversion for Group Life
• Update Form – Short Term Disability
• Employee Payroll Deduction Form

Dental Blue administration

• Dental Blue claim form
• Dental Blue Select claim form