AICK forms for enrollment, claims and more.
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-4SP) - Evidence of Insurability Form
(Form AICK 4C) - Evidence of Insurability Form (Spanish Version)
(Formulario de evidencia de asegurabilidad)
(Form AICK 4Ces) - Evidence of Insurability Form - use with AICK-4
(Form AICK 4EV) - Voluntary Life
(Form AICK 400) - Voluntary AD&D, Voluntary Short Term Disability, Voluntary Long Term Disability and Voluntary Life
(Form AICK 300) - Voluntary Short Term Disability Form
(Form AICK 8003)
Claim Forms
- Death Claim Form
(Form AICK 16) - Death Claim Form (Spanish Version)
(Formulario de reclamación por muerte)
(Form AICK 16es) - Disability Claim Form - STD, LTD and Waiver
(Form AICK 18) - Disability Claim Form - STD, LTD and Waiver (Spanish Version)
(Formulario de reclamación por discapacidad)
(Form AICK 18es) - 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) - Request for Change (Spanish Version)
(Formulario de cambio grupal)
(Form AICK 5es) - Application for Portability (Voluntary Life only)
(Form AICK 170) - Application for Portability (Spanish Version)
(Solicitud de portabilidad)
(Form AICK 170es) - Beneficiary Designation Form
(Form AICK 7) - Beneficiary Designation Form (Spanish Version)
(Formulario de designación de beneficiario)
(Form AICK 7es) - Notice of Conversion Privilege
(Form AICK 12) - Notice of Conversion Privilege (Spanish Version)
(Aviso de privilegio de conversión)
(Form AICK 12es) - Group Administrator Supply Order Form
- Notice of Terminated Employees
- Automatic Payment Authorization
(Form AICK 25A) - Automatic Payment Authorization (Spanish Version)
(Autorización de pago automático)
(Form AICK 25Aes) - Disabled Dependent Application
(AICK 21) - Waiver of Coverage
(AICK Waiver) - Waiver of Coverage (Spanish Version)
(Renuncia de inscripción Rechazar el seguro de vida grupal o de discapacidad)
(AICK Waiver ES)
Individual Coverage Forms
- Death Claim Form
(Form AICK 17) - Death Claim Form (Spanish Version)
(Formulario de reclamación por muerte)
(Form AICK 17es) - Individual Change Form
(Form AICK 6) - Individual Change Form (Spanish Version)
(Formulario de cambio individual)
(Form AICK 6es)
Group Pre-enrollment Forms
- Application for Group Insurance
(Form AICK 100) - Small Group Employer Application
(Form AICK 290)