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Group Administration Forms

We’ve provided access to some commonly used Group Administration forms. If you aren’t sure which ones you should use or don’t see the form you are looking for, please contact our Employee Benefits Department at (800) 322-0160, Extension 2814.

Employer’s Change Notice LG118 GR This form should be completed when you need to make changes in the coverage for your employees. Additional forms may be required. If so, they are listed at the bottom of this form.

Waiver of Insurance Benefits LG126 When an eligible employee or dependent declines coverage, this form must be completed.

Change of Beneficiary Request LG124 This form should be completed by an employee who is requesting a change of address, name, and/or beneficiary.

ENROLLMENT:

Dental Evidence of Insurability LG125-D This form is required when dental coverage is being applied for more than 31 days after the employee was eligible for coverage.

Illinois

Employee Application for Group Insurance LG196 IL This form can only be used for Illinois Groups with 51 or more employees. Illinois groups with 50 or fewer employees must use LG293.

Illinois Standard Health Employee Application LG293 This form is used for Illinois groups with 50 or fewer employees. For all other groups, use LG196 IL.

Indiana

Employee Application for Group Insurance LG196 IN This form can only be used for Indiana Groups.

Iowa

Employee Application for Group Insurance LG196 IA This form can only be used for Iowa Groups with 51 or more employees. Iowa groups with 50 or fewer employees must use LG196 U IA.

Iowa Small Group Uniform Employee Application for Group Health LG196 U IA This form is used for Iowa groups with 50 or fewer employees. For all other Iowa groups, use LG196 IA.

Ohio

Employee Application for Group Insurance LG196 OH This form can only be used for Ohio Groups.

Wisconsin

Employee Application for Group Insurance LG196 WI This form can only be used for Wisconsin Groups with 51 or more employees. Wisconsin groups with 50 or fewer employees must use OCI-26-501.

Wisconsin Small Group Uniform Employee Application for Group Health OCI-26-501 This form is used for Wisconsin groups with 50 or fewer employees. For all other Wisconsin groups, use LG196 WI.

CLAIMS:

Insured Supplemental Statement LC142 Used to provide updated proof of continual disability on a disability claim currently in benefit.

Disability Statement of the Insured LC171 Disability forms are used to file a claim for Individual disability income benefits or Group weekly benefits. You may contact the Life Claim Department at 800-371-9622 to discuss your claim.

Accidental Injury Report LG199 For claims related to an accidental injury, additional information is typically needed in order for us to process your employee’s health insurance claim. This form is used for accident claims being filed under your group’s Major Medical Plan.

Authorization to Disclose Medical Information for Customer Service LS253 We are only authorized to discuss your employees’ health information with the patient unless they provide authorization for us to discuss matters with someone else. Any insureds over the age of 17 must complete this form if they wish to authorize anyone to access their claim information for customer service purposes.

PartnersRx Payment Authorization LG287 Under some of our high deductible health plans, members are required to pay for their prescriptions in full at the pharmacy. Once they’ve reached the 100% benefit level, they may request that we begin paying their benefits directly to the pharmacy on their behalf to avoid paying at the time of purchase. This form can be completed to provide authorization of payments to the pharmacy.

Authorization for Use or Disclosure of PHI LS264 This form will need to be completed if we need to obtain records from your employee’s health care provider. It will give us authorization to get the records needed to process claims.

Claim Form LC106 This form is used when additional medical history information is needed on a claim. This form is NOT needed for most claim filings. Only have your employee complete this form if we’ve requested it from an employee for a claim.

COVERAGE CONTINUATION:

Illinois

Notice of Conversion LG110 If employees are no longer eligible under the group life policy, they have the right to convert their coverage to an individual policy. Refer to this notice and your policy for requirements or contact our Underwriting Department at (800) 322-0160, Extension 2816 or 2480.

Illinois Notice of Continuation Rights LG163 When certain criteria are met, employees have the right to continue group health coverage. (This does not apply to life coverage.) Coverage can last up to 12 months. See this notice for requirements or contact our Underwriting Department at (800) 322-0160, Extension 2816 or 2480.

Illinois Spousal/Dependent Continuation LG269 When certain criteria are met, an insured spouse can continue coverage up to 2 years. See this notice for requirements or contact our Underwriting Department at (800) 322-0160, Extension 2816 or 2480. (See also LG272.)

Illinois Spousal Continuation Election Form LG272 Use this form when the insured spouse continuation option is being elected. (See also LG269.)

Illinois Dependent Child Right to Continue LG270 When certain criteria are met, an insured dependent child can continue coverage up to 2 years. See this notice for requirements or contact our Underwriting Department at (800) 322-0160, Extension 2816 or 2480. (See also LG271.)

Illinois Dependent Child Continuation Election Form LG271 Use this form when the dependent child continuation option is being elected. (See also LG270.)

Indiana

Notice of Conversion Privilege LG243 If an employee is no longer eligible under the group life policy, that employee has the right to convert his or her coverage to an individual life insurance policy. Refer to this notice and your policy for requirements or contact our Underwriting Department at (800) 322-0160, Extension 2816 or 2480.

Ohio

Ohio Notice of Continuation Right LG283 When certain criteria are met, employees have the right to continue group health coverage. (Does not apply to life coverage.) Coverage can last up to 6 months. See this notice for requirements or contact our Underwriting Department at (800) 322-0160, Extension 2816 or 2480.

Wisconsin

Wisconsin Notice of Continuation Rights LG163WIS When certain criteria are met, employees have the right to continue group health coverage. (See LG173WIS for continuation of life coverage.) Coverage can last up to 18 months. See this notice for requirements or contact our Underwriting Department at (800) 322-0160, Extension 2816 or 2480.

Notice of Conversion Privilege LG173WIS If an employee is no longer eligible under the group life policy, that employee has the right to convert his or her coverage to an individual life insurance policy. Refer to this notice and your policy for requirements or contact our Underwriting Department at (800) 322-0160, Extension 2816 or 2480.

TEFRA/COBRA

Notice of Continuation Right – COBRA LG172 When certain criteria are met, employees and their dependents have the right to continue group health coverage. (This does not apply to life coverage.) See this notice for requirements or contact our Underwriting Department at (800) 322-0160, Extension 2816 or 2480. (See also LG178.)

COBRA Continuation of Coverage Election Form LG178 Use this form when the insured and/or dependent COBRA continuation option is being elected. (See also LG172.)

Call Toll-Free 1-800-322-0160