Tampa-Administered Forms for New York

Please note that The United States Life Insurance Company in the City of New York is the only approved underwriting company for the State of New York.

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—Claim, Change of Beneficiary, Reinstatement, etc.

Pre-Sale Back To Top

. 00305101-1098NY USL - Application for Group Voluntary Programs All NY 
. 06670220-1183NY USL - Master Application for Employee Benefits NY 
. 06673571-1005NY USL - Statement of Insurability for Group Programs NY 
. AGLC101519NY USL - Application for Individual Worksite Life Insurance NY

The above are the only state-specific forms. Additional forms can be found on the General Forms page.

Post-Sale Back To Top

. 06673221-1012NY USL - Application to Reinstate Group Insurance NY
. 06673221-1019NY USL - Beneficiary / Name Change Form NY 
. 06673571-1005NY USL- Statement of Insurability for Group Programs NY

The above is the only state-specific form. Additional forms can be found on the General Forms page.

Post-Policy Back To Top

.06673221-1006NY Request for Conversion to Group Term Life Insurance
.06673221-1020NY Refusal of Insurance Card
.06673221-1049NY Certification of Domestic Partnership
.06673221-1051NY Termination of Certification of Domestic Partnership
.06673221-1059NY Request to Continue Supplemental Medical Products
.06673221-1060NY Request to Continue Supplemental Medical Products

The above is the only state-specific form. Additional forms can be found on the General Forms page.