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    Service Forms

    Arizona residents should use only the Universal Claim Form to file claims.

    TitleForm#DescriptionAvailability
    Submit all wellness claims less than a year old online. Online Submit a wellness claim online. This form is available for online completion.You cannot view this form as a PDF.
    Loss of Life (Death) Notification Form Online Submit Loss of Life Notification online. This form is available for online completion.You cannot view this form as a PDF.
    Request For Service 05897 Use this PDF form to request changes to personal data, request a Beneficiary Change Form, or to exercise policy provisions. This form is not available for online completion.View this form as a PDF.
    Request For Service — Life 73712 This PDF form should be used to request a loan, withdraw, or cancellation/surrender of your life policy. This form is not available for online completion.View this form as a PDF.
    Universal Claim Form 73702 This PDF can be used to submit a claim for disability, cancer, accident, critical illness, and hospital confinement. This form is not available for online completion.View this form as a PDF.
    Request for Change of Ownership 14001 This PDF form should be used to update owner and/or contingent owner information on a policy. This form is not available for online completion.View this form as a PDF.
    Change of Beneficiary Form 17075 This PDF form should be used to add or modify the designated beneficiary on a policy. This form is not available for online completion.View this form as a PDF.
    Claim Form and Instructions - Group Short-Term Disability 19057 This PDF should be used to submit a claim under the Group Short-Term Disability policy offered by your employer. This form is not available for online completion.View this form as a PDF.
    Service Guide for Policyholders 43233 This helpful flier provides information on finding the most up-to-date claim forms, submitting a claim and selecting optional services on the claim form. The form also provides helpful tips about the claims process, how the policy works and when to contact the service center. This form is not available for online completion.View this form as a PDF.
    Continuing Disability Claim Form 46988 This PDF should be used to submit additional information for your on-going disability claim. This form is not available for online completion.View this form as a PDF.
    Express Filing of Pregnancy Claim 49507 This PDF should be used for the express filing of pregnancy claims once you deliver. If you are filing for complications prior to delivery, please complete the Universal Claim Form. This form is not available for online completion.View this form as a PDF.
    HIPAA Authorization 57644 This PDF should be completed and returned with each claim form submitted. This form is not available for online completion.View this form as a PDF.
    Claim Form - Catastrophic Accident 57930 This PDF should be used to submit a claim for the catastrophic accident benefit. This form is not available for online completion.View this form as a PDF.
    Claim Form - Group Supplemental Hospital Confinement 60316 This PDF should be used to submit a claim under the Group Supplemental Hospital policy offered by your employer, if available where you work. This form is not available for online completion.View this form as a PDF.
    Claim Form - Disability 64387 This PDF should be used to submit a disability claim. This form is not available for online completion.View this form as a PDF.
    Claim Form - Critical Illness 65017 This PDF should be used to submit a claim for the critical illness benefit. This form is not available for online completion.View this form as a PDF.
    Claim Form - Accident 67715 This PDF should be used to submit an accident claim. If you are also filing for disability benefits, please complete the Universal Claim Form. This form is not available for online completion.View this form as a PDF.
    Medical Bridge 3000 Doctor's Office Visit Benefit Claim Form 69121 This PDF should only be used to submit a claim form for a doctor's office visit if you have a Medical Bridge 3000 policy. This form is not available for online completion.View this form as a PDF.
    Express Filing for Health Screening Benefit Form 70067 This PDF should be used for the express filing of health screening claims that are over a year old. This form is not available for online completion.View this form as a PDF.
    Formularios de Servicio
    Título#formaDescripciónFormatos
    Formulario para la Designación de Beneficiario 51578 Este formulario se usa para designar un beneficiario primario o para seleccionar beneficiarios contingentes. This form is not available for online completion.View this form as a PDF.
    Formulario para cambio de Designación de Beneficiario 70089 Este formulario se usa para cambiar la designación de su beneficiario primario. This form is not available for online completion.View this form as a PDF.
    Formulario para la Presentación de una Reclamación 51164 Este formulario se puede usar para procesar su reclamación. This form is not available for online completion.View this form as a PDF.
    Formulario para Solicitar Servicio 18397 Use este formulario para cambiar su dirección u otra información personal, cambiar su beneficiario o para efectuar otros cambios relacionados con su póliza. This form is not available for online completion.View this form as a PDF.