EA Forms Last Audited: 1/26/2014

UNUM Forms

Form Number

Revision Date

Form Name

(Links to Plan Source Library)

Internal Use

AE-1107 1/08 Group Insurance Enrollment Form (Life, LTD & STD) EA IA
GZE-W-138 7/03  WEA Enrollment Card for Group Insurance RA IA
1335-03 4/07 Term Life and AD&D Insurance Enrollment R-FB EA IA
CL-1091 5/13 Life Claim/Accidental Death & Dismemberment Benefits EA  
CS-1110 12/09 Beneficiary Designation Form for Group Life & Group Accident Insurance EA IA
AE-1067 1/10 Life Insurance Conversion* RA  
1266-84 11/11 Group Life Insurance Disability Benefit Form* EA  
1143-01 1/12 Evidence of Insurability Form EA  
AE-1138 12/13 Life Insurance Election of Portability Coverage* EA  
19-46 4/07 Request for Change Group Life, STD & LTD* EA  
652-85 4/09 Request for Change Form EA  
AE-1107 01/08 Life, LTD & STD Enrollment EA IA



LTD/STD Claim For Income Protection Benefits

19-46 4/07 Request for Change Group Life, STD & LTD* EA  
CL-1158 11/13 Long Term Care Claim EA  
6720-03 1/08 Medical Authorization Form EA  
7041-04 1/08 Application - GLTC - Evidence of Insurability - Generic EA  
7017-04 1/08 Long Term Care Evidence of Insurability - ME & WA EA  
1237-96 9/07 Long Term Care Personal Worksheet EA  
1444-95 1/08 Long Term Care Replacement Notice EA  
1718-94 7/03 Life and Health Guaranty Notice - MT EA  
1375-96 1/08 Things You Should Know Before You Buy Long Term Care EA  
1311-96 6/05 Notice Of Premium Lapse RA  
1504-95 7/10 Medicare Disclosure Form EA  
*These forms can be filled out online and then printed.EA
Link directly to the forms section of Unum's website



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Please note:  Any form in the PlanSource Library that is coded "RA" means that we are unable to locate the form on the carrier's website.  You may need to contact your carrier representative or broker to obtain the most current form.

If you can't find the form that you're looking for, please contact your insurance broker or HR Administrator.