Insurance Forms

Staff Contact: Marybelle Hansen

• Group Census Update Form
  

Group Life Insurance	Long Term Disability	Dental Insurance	Short Term Disability	Fusion Eye Care
Enrollment Form Accelerated Benefit Form 15 pages Basic Life/ADD and Supplemental Life Claim Form 2 pages Beneficiary Designation Form 2 pages Evidence of Insurability Form 4 pages Life Conversion Form 4 pages Waiver of Premium Claim Form 3 pages Dismemberment Claim Form 2 pages	Enrollment Form LTD Claim Form Evidence of Insurability Form 4 pages HIPAA Authorization – please complete for claims Employee Assistance Program Flyer Employee Assistance Program Summary	Enrollment Form Dental Application (New members) Claim Form 2 pages Benefit and Claims Information and Participating Provide Dentist Notice of Insurance Continuation Form 2 pages First Ameritas Privacy Policy 2 pages I.D. Card 2 pages Nominating Dentist Form 2 pages Understanding Your Dental Rewards	Enrollment Form NYS DBL Claim Form 2 pages NYS Disability Claim Address STD Claim Form HIPAA Authorization – please complete for STD claims only	Fusion ID Card Fusion Claim Form

• The 2007 Summary Annual Report for The Business Council's Insurance Fund.
• The 2006 Summary Annual Report for The Business Council's Insurance Fund.
• The 2005 Summary Annual Report for The Business Council's Insurance Fund.
• The 2004 Summary Annual Report for The Business Council's Insurance Fund.
• Internal Revenue Code Section 79, Table I for Group Life Insurance
  
  

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