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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-4 Español)
Evidence of Insurability Form
(Form AICK-4C)
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)
Questions? Contact your policyholder representative.
In Topeka
785-273-9804
Toll-free
1-800-530-5989
Fax (Claims & Forms)
785-290-0727
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