Tampa-Administered General Forms

The forms listed below are for use in states that do not require state-specific forms. For state-specific forms, click "By State" and select the applicable state. Important: Many states require state-specific forms to be used when applying for coverage. Please check state-specific forms prior to downloading any general forms.

Forms are separated in three categories:

  • Pre-Sale Forms—Licensing, Master Applications, Statement of Insurability, etc. 
  • Post-Sale Forms—Enrollment, Individual Applications, Refusal of Insurance, Reporting Summary etc.

  • Post-Policy Forms—Amendments, Claim, Change of Beneficiary, Reinstatement, etc.

Pre-Sale Back To Top

. 06670220-1183  Master Application for Employee Benefits
. 06670220-2000F Master Application for Employee Benefits For All Products in States-AR, OH, RI, TN
. 06673131-1005  Master Application for Group Critical Illness Insurance Policy
. 06670220-1043 AGLA Sold Case
. 06670220-2000 Master Application for Employee Benefits For All Products in States-AL, AK, AZ, CO, DE, ID, IL, IA, MI, MN, MS, NV, NB, NV, NH, NM, ND, NC, OK, PA, SC, OR, UT, VA, WV, WI, WY
. 06670220-3461 New Case Submission Checklist 
. 06673131-1006 Master Application for Group Accident & Sickness Indemnity Insurance Policy
. 06673221-1009 Group Employee Enrollment Form 
. 06673571-1005 Statement of Insurability for Group Programs
. 06673571-1098 Application for Group Voluntary Programs All 
. 06673571-1496 Application for Group Voluntary Programs Life & AD&D
. AGLC101475 Case Data Sheet
. AGLC101519 Application for Life Insurance - Multi-state
. 06675006-1555 EBS Employers Agreement For Employee Paid Products 
. 06675006-2594 Policy Amendment Guide FAQs 
. Tampa Administered State EOI Guide

Licensing
. 00302301-1025 Individual Agent Appointment Application 
. 00302301-1026 Corporate/Executive Appointment Application
. 00302301-1027 Hierarchy Structure
. 00302301-1029 Assignment of Commission Agreement
. 06673522-1003 Contacting & Appointment Coversheet for Cross Sell
. 06673522-1005 Producer Address Change Form
. 06678004-1003 Producer Agreement
. 06678004-1004 MGA Agreement
. 06678004-1006 Solicitor Without Per Diem Compensation Agreement
. 06678004-1007 Annualization Agreement

Post-Sale Back To Top

. 06670220-1042 Enrollment Census with Dependent Data
.06673131-1007 Individual Enrollment Form for Group Accident & Sickness Indemnity Insurance Policy
. 06673221-1004 Acknowledgement/Election of Cobra Continuation Right
. 06673221-1005 Reporting Summary For Reporting Salary Changes and Terminations
. 06673221-1009 Group Employee Enrollment Form
. 06673221-1012 Application to Reinstate Group Insurance
. 06673221-1019 Request for Change of Beneficiary/Name Change
. 06673221-1020 Refusal of Insurance Card
. 06673221-1049 Affidavit of Domestic Partnership 
. 06673221-1051 Affidavit of Termination of Domestic Partnership
. 06673221-1062 Request a Quote for Conversion of Group Term to Individual Whole Life 
. 06673571-1003 Individual Application for Group Critical Illness Insurance
. 06673571-1004 Individual Application for Group Accident and Sickness Indemnity Insurance
. 06673571-1005 Statement of Insurability for Group Programs
. 06673571-1098 Application for Group Voluntary Programs All Products
. 06673571-1496 Application for Group Voluntary Programs Life & AD&D Only


Post-Policy Back To Top

. 00303401-1132 Dental Claim Form 
. 00304201-1079 Proof of Group Death Claim Form
. 00304201-1015 Proof of Group Death Claim Form--Dependent Life
. 00304201-1020USL Claimant's Statement
. 00304201-1021USL Employer's Statement
. 00304201-1022USL Attending Physician's Statement
. 00304201-1086USL Proof of Accidental Injury, Dismemberment 
. 06233413-1005 W2 Prep Authorization Form 
. 06670321-1008 Health Screening Benefit Claim Form 
. 06670321-1009 Critical Illness Claim Form 
. 06670321-1010 Cancer Indemnity Expense Claim Form 
. 06670321-1022 Group Accident Indemnity and Group Accident & Sickness Indemnity Insurance Claim Form
. 06673221-1006 Request for Portability to Group Term Life Insurance  
. 06673221-1019 Request for Change of Beneficiary/Name Change  
. 06673221-1049 Certification of Domestic Partnership 
. 06673221-1051 Affidavit of Termination of Domestic Partnership
.06673221-1059 Request to Continue Supplemental Medical Products 
.06673221-1063 Enrollment Form for Group Voluntary Vision & Dental
. 06673412-9006 Disability Claim Packet 
. 06675006-1028 Vision Out of Network Claim Form
.  06675006-2594 Policy Amendment Guide FAQs  
. AGLC100735 Payroll Deduction Authorization
. ACCREQUSL AG Life Accelerated Group Life Benefits


 

Product Specs Back To Top

Ancillary
Ancillary Healthcare products help employees manage the costs of their families' dental and vision care.

. 06675006-1677 Group PPO Dental Employer Funded Specifications
. 06675006-1727 Group PPO Dental Employee Paid Specifications 
. 06675006-1678 Group Indemnity Dental Employer Funded Specifications
. 06675006-1728 Group Indemnity Dental Employee Paid Specifications
. 06675006-1665 Group Scheduled Reimbursement Dental Specifications
. 06675006-1667 Group High-Low Choice Dental A Specifications
. 06675006-1698 Group High-Low Choice Dental B Specifications
. 06675006-1699 Group High-Low Choice Dental C Specifications
. 06675006-1700 Group High-Low Choice Dental D Specifications
. 06675006-1701 Group High-Low Choice Dental E Specifications
. 06675006-2577 Schedule of Covered Dental Services 
. 06675006-2578 Reimbursement Schedule for Low-Option Dental Plan
. 06675006-1384 Group Discount Dental Specifications 
. 06675006-1386 Group Vision Specifications

Protection
Protection products help employees protect their families against the financial challenges that death or serious injury can bring about.

. 06675006-1365 Term MVP Specifications
. 06675006-2313 Group AD&D Specifications
. 06675006-2314 Group Term Life Specifications
. 06675006-2331 Platinum Universal Life(SM) Map
. 06675006-2336 Platinum Universal Life(SM) Specifications
. 06675006-2336NY Platinum Universal Life(SM) Specifications NY

Income Replacement
Income Replacement products provide a source of income should a disability ever prevent an employee from working.

. 06675006-1377 DisabilityCare Specifications
. 06675006-1378 Group Short-Term Disability Specifications
. 06675006-1379 Group Long-Term Disability Specifications
. 06675006-1380 New York Disability Benefits Law (NY DBL) Group Plan Specifications
. 06675006-1407 New Jersey Temporary Disability Benefits (NJTDB) Group Plan Specifications
. 06675006-1613 Family Medical Leave Act Administration Program Specifications

Supplemental Medical
Supplemental Medical products help address the often extensive costs of a critical illness or extended hospital stay.

. 06675006-1372 Group CancerCare Specifications
. 06675006-1375 Group CriticalCare Specifications
. 06675006-1369 Group EmergencyCare Specifications
. 06675006-1376 Group HospitalCare Specifications
. 06675006-1373 CancerCare Specifications
. 06675006-1374 CriticalCare Specifications
. 06675006-1370 EmergencyCare Specifications
. 06675006-1873 Limited HealthCare Specifications
. 06675006-1873NY Limited HealthCare Specifications NY