DOWNLOADABLE FORMS

Download the forms you need to efficiently administer your ancillary products.

• Life, Disability, Accident, Critical Illness, Vision and Dental Enrollment and Change Form — You may use this form to enroll in any or all of our group ancillary products.
• Evidence of Insurability — Medical Evidence of Insurability for coverage changes.
• Portability Application – Life — Use to continue Life coverage due to terminate.
• Portability Application – Accident — Use to continue Accident coverage due to terminate.
• Portability Application – Critical Illness — Use to continue Critical Illness coverage due to terminate.
• Application to Convert Group Life Insurance — Conversion allows Employees and their covered dependents to convert some of their Basic Life and/or Voluntary Life insurance to an individual whole life policy.
• Benefits Manager Registration – Use to register for secure online group administration.
• Group Application Packet – Contains all forms needed to apply for coverage. Must be submitted with the Producer Transmittal form.
• Producer Transmittal – This form is to be completed by the producer regarding coverage. Must be submitted with the Group Application.
• Third Party Administrator Questionnaire – Complete this form if a third party will be administering your plan.
• FICA Tax/W2 Agreement – Must be included with all Disability group applications.
• Broker Authorization for Group Changes – This form is to be completed by the Group for Broker Authorizations or to revoke Broker Authorizations for group changes. Must be submitted with Group Transmittal.
• Policyholder Vendor Authorization/Change Form – This form is to be completed if the Group uses a third-party administrator. Must be submitted with Group Transmittal.
• Accidental Death & Dismemberment Claim Form
• Accelerated Death Benefit Claim Form
• Critical illness (Specified Disease) Claim Form
• Critical Illness Wellness Benefit Claim Form
• Accident/Critical Illness Wellness Benefit Claim Form
• Accident Claim Form
• Life Insurance Claim Form
• Life Insurance Claim Form - Spanish
• Long-Term Disability Claim Form
• Long-Term Disability Claim Form - Spanish
• Short-Term Disability Claim Form
• Short-Term Disability Claim Form - Spanish
• Vision Claim Form
• Waiver of Premium Claim Form
• Long-Term Disability Conversion Kit

Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS^®, BLUE SHIELD^® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.