Customer Administration Forms

---

CUSTOMER ADMINISTRATION FORMS

Enrollment Instructions | Enrollment Forms | Claim Forms | Administration Forms

Enrollment Instructions

Life and Disability

Evidence of Insurability Instructions

Dental and Vision

Enrollment Forms

Life

• Enrollment Form
• Beneficiary Designation Form
• Evidence of Insurability Form

Disability

• Short Term Disability Enrollment Form
• Long Term Disability Enrollment Form
• Evidence of Insurability Form

Dental

• 2 Tier Basic Plan | 2 Tier High Plan
• 3 Tier Basic Plan | 3 Tier High Plan
• 4 Tier Basic Plan | 4 Tier High Plan

Vision

• Vision Enrollment Form

Claim Forms

Claim Submission Information

Life

STD

LTD

Dental

Vision

Customers with both DBL and STD

For customers that have both STD and DBL coverages through The Business Council, please submit the AXA STD claim form to both Maxon(DBL) and AXA(GRP).  Your e-mail notification should include both vendors so that each can coordinate their claim efforts.

• Maxon (DBL claim paying vendor)
  Email Address: [email protected]
  Fax: (845) 985-2249
   
• GRP (STD claim paying vendor)
  E-mail Address: [email protected]
  Fax: (855) 864-0530
  STD

DBL/PFL

• DBL Claim Form(A&B)
• DBL (C)
• PFL-Care for Family
• PFL-Bonding
• PFL-Military

Administration Forms

Life

• Basic & Supplemental Life Portability
• Supplemental Life Portability
• Beneficiary Change
• Conversion

Dental

• COBRA
• ID Cards
• Privacy

Vision

• COBRA
• ID Cards
• Privacy