Group Forms

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If you're covered for group life or disability, or you administer group benefits for a New York group policy, browse this list of frequently-used forms.

Looking for forms for non-New York policies? Click here.

Form Nbr

Description

Dental and Vision

XGR/2262

SLHIC (U.S.) Dental Claim Statement

XGR/2329

Dental Claim Form for New York State School Trust - SLHIC (U.S.)

XGR/2326

Vision Claim Form - SLHIC (U.S.)

XGR/2330

Vision Claim Form for New York State School Trust - SLHIC (U.S.)

Enrollment

XNYGR/1632

Group Enrollment Form (NY)

XNYGR/862

Life/AD&D-Only Enrollment Form (non-contrib) (NY)

LIFE_ONLY_NONCONT_NY

Life Only Enrollment Form (non-contrib) (NY)

XNYGR/1356

Short Term Disability Enrollment Form (NY)

SLNY_ENROLL_INSTR_SP

Enrollment Instruction (NY) - Spanish

XNYGR/646-SP

Enrollment Form - Spanish Version (NY)

XNYGR/854

Beneficiary Designation (NY)

XNYGR/854-SP

Beneficiary Designation Form (NY) - Spanish

Evidence of Insurability

XNYGR/1480

EOI Application (NY)

NYGR/1533

Evidence of Insurability Employee Brochure (NY)

Group Life and AD&D

XNYGR/20

Life Conversion Notice (NY)

XNYGR/2362

Group Death Claim Packet (NY)

XNYGR/1520

Group Life Benefits Claim Packet (NY)

XNYGR/854

Beneficiary Designation (NY)

XNYGR/854-SP

Beneficiary Designation Form (NY) - Spanish

Long Term Disability

XNYGR/1643

Long Term Disability Claim Employer's Statement (NY)

XNYGR/1644

Long Term Disability Claim Employee's Statement (NY)

XNYGR/1645

Long Term Disability Claim Attending Physician's Statement (NY)

XNYGR/1306

LTD Conversion Notice (NY)

XNYGR/677

LTD Conversion Application (NY)

Miscellaneous

XNYGR/1386

Authorization (Complies with HIPAA) (NY)

XNYGR/2695

Privacy Notice (NY)

XNYGR/1278

ERISA Booklet Endorsement (NY)

XNYGR/2824

W-2 Tax Reporting Service Agreement (NY) (STD and/or LTD)

Premium/Billing

XNYGR/150

Statement of Premiums Due (NY)

XNYGR/1458

List Billing Change Form (NY)

XNYGR/232

Premium Statement for Life Step-Rates (NY)

XNYGR/1258

Stop-Loss Statement of Premium Due (NY)

Short Term Disability

XNYGR/2604

Short Term Disability Claim Packet (NY)

DB 450

DBL Claim Form

Stop-Loss

XNYGR/1201

Specific Stop-Loss Claim/50% Notice (NY)

XNYGR/1349

Stop-Loss Simultaneous Reimbursement (NY)

XNYGR/1202

Aggregate Monthly Claims Report (NY)

XNYGR/1258

Stop-Loss Statement of Premium Due (NY)

XNYGR/1684

Stop-Loss Direct Deposit Form (NY)

SunAdvisor®

XNYGR/1018

SunAdvisor® Claim Packet (NY)

SLPC5578


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