Forms for Group Benefits Plan Administrators
For Selectpac plans with 3 to 35 plan members
The following forms are for Plan Administrator use only. If you’re a group plan member looking for claim forms, go to the Group Plan Members > Forms page.
These documents are in PDF format. To view and print them, you need Adobe Acrobat Reader Version 4.0 or higher, which you can download, at no cost, from the Adobe website.
Note: Many of the forms can be completed on screen, by clicking in the space provided for writing and typing in your information. After printing the completed form, you will need to add any required signatures and dates by hand before you submit the form.
- Application for group coverage
Use this form to submit information needed to enroll new plan members in a group benefits plan.
- Employee Change form
Use this form to update information about plan members and/or their dependants.
- Group Insurance Adjustments M266(SEL) BIL
Use this form to summarize new or updated information about plan members and/or dependants, and may require the Application for Group Coverage or Employee Change forms above to be attached. (Types of changes that apply are listed in the "Reason Codes" section on the form.)
To find the CANUS Adjustments form (M5840 BIL) and other CANUS forms, go to the CANUS Forms for Plan Administrators page.
- Trustee Appointment M6242 BIL
Use this form to designate a trustee for a beneficiary who is a minor or who is legally unable to manage their own affairs.
- Consent to Change of Irrevocable Beneficiary M6320 BIL
Use this form to obtain consent for removal of a beneficiary that has been designated irrevocable.
- Irrevocable Beneficiary Designation M6348 BIL
Use this form to designate a beneficiary as irrevocable.
- Application for Non-Smoker Rate
Use the designated form to apply for a change from a smoker rate to a non-smoker rate.
- Evidence of Insurability M6129
Use this form to submit the plan member information needed to apply for group benefits which require medical underwriting, such as Optional Life, Excess Life and LTD, Supplemental Life and Late applicants.
- Evidence of Insurability M5995(CHOLIFE)
Use this form to submit the information needed to apply for group benefits which require medical underwriting. Use this form instead of M6129 when your plan includes Child Optional Life.
- Evidence of Insurability - Critical Illness M5995(CI)
Use this form to submit the plan member information needed to apply for Group Critical Illness coverage, which requires medical underwriting.