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

. 06670220-2000 Master Application for Employee Benefits (For All Products in AL, AK, AZ, CA, CO, DE, ID, IL, IA, MI, MN, MS, NV, NB, NV, NH, NM, ND, NC, OK, PA, SC, OR, UT, VA, WV, WI, WY)
. 06670220-2000F Master Application for Employee Benefits (For All Products in AR, OH, RI, TN)
. 06670220-1183 Master Application for Employee Benefits (For Massachusetts Only)
. 06673131-1005 Master Application for Group Critical Illness Insurance Policy
. 06673131-1006 Master Application for Group Accident & Sickness Indemnity Insurance Policy
. 06673571-1098 Application for Group Voluntary Programs All 
. 06673571-1496 Application for Group Voluntary Programs Life & AD&D
. AGLC101519 Application for Life Insurance - Multi-state
. 06670220-1043 AGLA Sold Case
. 06670220-3461 New Case Submission Checklist 
. 06673221-1009 Group Employee Enrollment Form 
. 06673571-1005 Statement of Insurability for Group Programs
. AGLC101475 Case Data Sheet
. 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
. 06673221-1020 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
. 06673221-1049 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
. EYEMED 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