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Forms

If you are unsure what form to use, please call your Policyholder Rep at 785-273-9804 (in Topeka) or toll-free at 800-530-5989.

Fax number: Forms 785-290-0727
                    Claims 785-273-6121

Employee Enrollment Forms

• Basic Coverage ― Term Life, AD&D, Dependent Life, Short Term Disability and Long Term Disability
  (Form AICK-4)
• Basic Coverage (Spanish Version) - Term Life, AD&D, Dependent Life, Short Term Disability and Long Term Disability
  (Formulario De Inscripción - Para Empleados Para Coberturagrupal)
  (Form AICK-4 Español)
• Evidence of Insurability Form
  (Form AICK-4C)
• Voluntary Life
  (Form AICK-400)
• Voluntary AD&D, Voluntary Short Term Disability, Voluntary Long Term Disability and Voluntary Life
  (Form AICK-300)
• Small Group Basic Coverage
  (Form AICK-29)
• Small Group Evidence of Insurability
  (Form AICK-29EV)

Claim Forms

• Death Claim Form
  (Form AICK-16)
  
• Disability Claim Form - STD, LTD and Waiver
  (Form AICK-18)
• LTD Payment Options
  (AICK-49)
• HIPAA Authorization
  (AICK-41A)
• Medical History
  (AICK-46)
• Continuance of Disability
  (AICK-24)
  

Miscellaneous Forms

• Request for Change ― Change of Beneficiary, Name change, etc.
  (Form AICK-5)
• Application for Portability (Voluntary Life only)
  (Form AICK-170)
• Notice of Conversion Privilege
  (Form AICK-12)
• Group Administrator Supply Order Form
• Notice of Terminated Employees
  
• Automatic Payment Authorization
  (Form AICK-25A)
• Handicapped Dependent [Child] Application
  (AICK -21)
• Waiver of Coverage
  (AICK WAIVER)

Group Pre-enrollment Forms

• Application for Group Insurance
  (Form AICK-100)
• Small Group Employer Application
  (Form AICK-290)
  
• Voluntary Term Life Insurance, Employer Participation Application Advance Business Trust
  (Form AICK-210)
  
• Request for Proposal - Basic
  
• Request for Proposal - LTD
  

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Blue Cross and Blue Shield of Kansas and Advance Insurance Company of Kansas
are Independent Licensees of the Blue Cross and Blue Shield Association.
Blue Cross and Blue Shield of Kansas serves all counties in Kansas except Johnson and Wyandotte.
® Registered Trademarks of the Blue Cross and Blue Shield Association.

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