Special markets forms
Special Markets Forms
Client Change Forms
- Request for Pre-Authorized Debit (PAD) Payment PDF (210.68 kB)
- Request to Add a Child to Your Existing Plan PDF (93 kB)
- Termination of Coverage Request PDF (121.31 kB)
- Supplemental Questionnaire for Dependent Child Insurance PDF (195 kB)
- Name and Address Change PDF (81.05 kB)
- Request for Non-Smoker Rates PDF (273.48 kB)
- Beneficiary Designation Change PDF (113.51 kB)
Claims Forms
Please contact our Claims Department toll-free at 1‑800‑266‑5667 for the appropriate form and details on claims procedures.
Forms for group plan administrators
Benefits Administrator Forms
- Basic Group Critical Illness Insurance Enrolment Request Form (Employee and Dependent Child) PDF (141.13 kB)
- Group Insurance Change Request Form PDF (90.03 kB)
- Basic Group Critical Illness Insurance Enrolment Request Form (Employee Only) PDF (64.01 kB)
- Late Application for Spouse PDF (273.47 kB)
- Late Application for Dependent Child PDF (171.33 kB)
- Late Application for Employee PDF (185.57 kB)
Conversion Forms
- Critical Illness Insurance Conversion Request Form PDF (309.02 kB)
- Term Life Insurance Conversion Request Form PDF (59.85 kB)
Please contact our Client Service Department toll-free at 1‑800‑266‑5667 for the appropriate form and details on conversion procedures.