Forms

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)
  Formulario de evidencia de asegurabilidad (Spanish Version)
• 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)
  
• 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)
• Beneficiary Designation Form
  (Form AICK-7)
• 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)
• Waiver of Coverage (Spanish Version)
  (Renuncia de inscripción Rechazar el seguro de vida grupal o de discapacidad)
  (AICK WAIVER Español)

Individual Coverage Forms

• Individual Change Form
  (AICK-6)

Group Pre-enrollment Forms

• Application for Group Insurance
  (Form AICK-100)
• Small Group Employer Application
  (Form AICK-290)