| Insurance Company Policy Type | Forms |
|---|---|
|
Accident Advantage |
A-9520; A-12000 |
|
Short-Term Disability |
A57600OK |
Supplemental Insurance Policies Forms
Quick Links
American Family Life Assurance Company
American Fidelity Assurance Co.
American Public Life Insurance Co.
Bankers Fidelity Life Insurance Co.
Colonial Life & Accident Insurance Company
Combined Insurance Company of America
Equipoint Partners/DBA Pre Med Defender
Liberty National Life Insurance Co.
Manhattan Life Assurance Company of America
National Teachers Associates Life Insurance Co.
American Family Life Assurance Company (AFLAC)
Payroll Code: AI03 -- Billing Unit: American Family Life Assurance Co.
Riders:
| Insurance Company Policy Type | Forms |
|---|---|
|
-Value Rider |
A57650OK |
|
-Additional Units of Disability Benefit Rider |
A57653 |
|
Cancer Indemnity – Option 1 |
B70100OK |
|
Cancer Indemnity – Option 2 |
B70200OK |
|
Cancer Indemnity – Option 3 |
B70300OK |
Riders:
| Insurance Company Policy Type | Forms |
|---|---|
|
-Initial Diagnosis Building Benefit Rider |
B70050OK |
|
-Specified-Disease Benefit Rider |
B70051OK |
|
-Dependent Child Rider |
B70052OK |
|
Hospital Confinement Indemnity – Option 1 |
B40100OK |
Riders:
| Insurance Company Policy Type | Forms |
|---|---|
|
-Extended Benefits Rider |
B40050 |
|
-Hospital Stay and Surgical Care Rider |
B40051 |
|
Specified Health Event – Option 1 |
A74100OK |
|
Specified Health Event – Option 2 |
A74200OK |
|
Specified Health Event – Option 3 |
A74300OK |
|
Term Life Insurance – 10 Year |
ICC1368200 |
|
Term Life Insurance – 20 Year |
ICC1368300 |
|
Term Life Insurance – 30 Year |
ICC1368400 |
American Fidelity Assurance Co.
Payroll Code: AI09
| Insurance Company Policy Type | Forms |
|---|---|
|
Renewable & Convertible Term Life Insurance Policy |
ICC14 RCTL14 |
|
Whole Life To Age 121 Insurance Policy |
ICC14 WL14 |
|
Accelerated Benefit for Critical Illness Rider |
ICC14 LR203 |
|
Accelerated Benefit for Long Term Illness Rider |
ICC16 LR204.R416 |
|
Waiver of Premium Rider |
ICC14 LR205 |
|
Level Term Insurance for Children Rider |
ICC14 LR206 |
|
Renewable & Convertible Term Rider with Accelerated Benefit for Terminal Condition Provision |
ICC14 LR207 |
|
Accidental Death & Dismemberment Rider |
ICC14 LR208 |
|
Limited Benefit Specified Disease Cancer Policy |
C1106(0K) |
|
Critical Illness Rider |
AMDl-239(0K) |
|
Hospital Intensive Care Unit Rider |
AMDl-240(0K) |
|
Accident Only Policy |
A0-03(0K) |
|
Accident Only Benefit Enhancement Rider |
AMD1258 |
|
Accident Disability Income Rider - 24-Hour Covewrage |
AMDl-224(0K) |
|
Group Critical Illness Limited Benefit |
G9250K, G925 |
|
Spouse Limited Benefit Rider |
AMD2117 |
|
Group Supplemental Limited Benefit Medical Expense |
G9230K, G923 |
|
Group Hospital Indemnity |
G14020K, G1402 |
American Public Life Insurance Co.
Payroll Code: AI05 -- Billing Unit: American Public Life Insurance Co.
| Insurance Company Policy Type | Forms |
|---|---|
|
Accident Expense, Death and Dismemberment |
A-2 (3/80) |
|
Cancer and Specified Disease |
S-CSD-1 (6/83) |
|
Cancer and Specified Disease |
BDCPA (7/83) |
|
Cancer and Specified Disease |
APL-1 (6/86) |
|
Cancer and Specified Disease |
GCPW (6/86) |
|
Cancer and Specified Disease |
APLIC-1 (10/90) |
|
Cancer and Specified Disease |
APLIC-2 (10/90) |
|
Cancer and Specified Disease |
APLIC-3 (10/90) |
|
Convertible Term Life/Decr. Term |
S-900 (1/89) |
|
Hospital Intensive Care/Coronary Care |
IC-CC-1 (Rev. 8/82) |
|
Hospital Intensive Care/Coronary Care |
IC-CC-2 (6/86) |
|
Heart Attack/Stroke |
HA/S-1 (6/86) |
|
Intensive Care/Coronary Care |
IC/CC-3 (2/90) |
|
Whole Life |
WL-1 (11/86) |
Assurity Life Insurance Co.
Payroll Code: AI49 -- Billing Unit: Assurity Life Insurance Co.
| Insurance Company Policy Type | Forms |
|---|---|
|
Return of Premium Rider |
CIR018 |
|
Disability Waiver |
CIR016 |
|
Automatic Benefit Increase |
A-DR205 |
|
Return of Premium Rider |
A-DR208 |
|
Residual Benefit Rider |
R-D220 |
|
Guaranteed Insurability Rider |
RD221 |
|
Hospital Benefit Rider |
A-DR202 |
|
Home Modification Rider |
A-DR210 |
|
Retroactive Injury Benefit |
RD222 |
|
Critical Illness |
CI005 (OK) |
|
Accidental Death Benefit |
A-R126 (OK) |
|
Spouse Rider |
CIR-010 (OK) |
|
Dependent Child Rider |
CIR014 (OK) |
|
Critical Illness |
CI007 (OK) |
|
Spouse Rider |
CIR012 (OK) |
|
Children's Rider |
CIR020 (OK) |
|
Personal Disability |
A-D100 (OK) |
|
Supplemental DI Rider |
A-DR200 (9/95) |
|
Simplified Life |
A-LN00 (OK) |
|
Accident Expense Policy |
AAW-A117OK |
|
Family Rider |
AAW-AR260OK |
|
Outpatient Sickness |
AAW-DR225OK |
|
Intensive Care Benefit |
AAW-DR226OK |
|
Private Duty Nurse |
AAW-DR227OK |
|
Surgical and Anesthesia and Additional Benefits |
AAW-DR228OK |
|
Surgical Anesthesia and Additional Benefits |
AAW-DR230OK |
|
Disability Income Policy |
AAW-D113OK |
|
Sickness Benefits |
AAW-DR220N0 |
|
Emergency Accident |
AAW-DR221 |
|
Accidental Death and Dismemberment |
AAW-DR222 |
|
Cancer Expense |
AAW-C120 OK |
|
Cancer Expense Rider |
AAW-CR261 OK |
|
Cancer Expense Rider |
AAW-CR262 OK |
|
Cancer Expense Rider |
AAW-CR263 OK |
|
Cancer Expense Rider |
AAW-CR264 OK |
|
Accident Expense |
W A200 OK |
|
Accident Expense (Off the Job) |
W A205 OK |
|
Short Term Disability Income Rider |
R WA201 OK |
|
Short Term Disability Income Rider (Off the Job) |
R WA251 OK |
|
Universal Life |
9900 |
|
Accidental Death Rider |
0027 |
|
Level Term Insurance Rider (20-Year) |
0150 |
|
Additional Insured Rider Level Term (20-Year) |
0151 |
|
Rider to Apply Monthly Payments and Waive Monthly Deductions in Case of Total Disability |
0153 |
Bankers Fidelity Life Insurance Co.
Payroll Code: AI64 -- Billing Unit: American Trustee, Inc.
| Insurance Company Policy Type | Forms |
|---|---|
|
Group Accident Medical Insurance |
Group Master Policy B 21301- MP-E |
|
Group Accident Medical Expense |
B 21301 CRT-E Certificate of Insurance |
|
Accident Indemnity Policy |
B 21302 OK- Policy |
|
Accident Indemnity Policy |
B 21302 R1 Rider |
|
Accident Indemnity Policy |
B 21302 R2 Rider |
|
Accident Indemnity Policy |
B 21302 R3 Rider |
|
Accident Indemnity Policy |
B 21302 R4 Rider |
|
Critical Illness |
B 21303 OK – Policy |
|
Group Hospital Indemnity |
B 21304 MP-E Master Policy |
|
Group Hospital Indemnity |
B 21304 CRT-E Certification of Insurance |
|
Cancer Expense Policy |
B 9401 OK (01-01)- Policy |
|
Cancer Expense Policy |
B 9401 R1-1 OK (01-01) Rider |
|
Cancer Expense Policy |
B 9401 R1-2 OK (01-01) Rider |
|
Cancer Expense Policy |
B 9401 R1-3 OK (01-01) Rider |
|
Short Term Care Policy |
B 9305 OK – Policy |
|
Disability Income Policy |
B 8722 OK – Policy |
|
Disability Income Policy |
B 8722 R1- Rider |
|
Disability Income Policy |
B 20702 OK – Policy |
|
Term Life Insurance Policy |
B 20601 OK – Policy |
|
Term Life Insurance Policy |
B 0211-2 CIBR – Rider |
|
Whole Term Insurance Policy |
B 20803 OK – Policy |
Colonial Life & Accident Insurance Company
Payroll Code: AI02 -- Billing Unit: Colonial Life Insurance and Accident Insurance Co.
| Insurance Company Policy Type | Forms |
|---|---|
|
Cancer Assist |
CanAssist-OK |
|
Critical Illness 1.0 |
CI-1.0-OK |
|
Individual Medical Bridge |
IMB7000-OK |
|
Individual Accident 4000 |
IAC4000-OK |
|
Term Life 5000 |
ICC18-ITL5000 |
|
Whole Life 5000 |
ICC19-IWL5000 |
|
Individual Short Term Disability 3000 |
ISTD3000-OK |
Combined Insurance Company of America, A Chubb Company
Payroll Code: AI69
| Insurance Company Policy Type | Forms |
|---|---|
|
Accident Only |
ACEH-129919019ACE |
|
Critical Illness |
ACEH-129909978ACE |
|
Individual Hospital Indemity |
ACEH-132885849 & ACEH-133130263 |
|
Individual Universal Life |
ACHE-132007898 Form #36002-OK619 |
Equipoint Partners/DBA Pre Med Defender
Payroll Code: AI68
| Insurance Company Policy Type | Forms |
|---|---|
|
Group Supplemental Benefit Certificate |
NGSBCRT-OK 3/17 |
Kemper Benefits
Payroll Code: AI64 - -- Billing Unit: American Trustee, Inc.
| Insurance Company Policy Type | Forms |
|---|---|
|
Accident Medical Expense - Certificate |
KB-MAE-CER-1301-0K |
|
Accident Medical Expense - Spouse Rider |
KB-MA-SR-1301 |
|
Accident Medical Expense -Child(ren) Rider |
KB-MA-CR-1301-0K |
|
Accident Medical Expense - Accidental Death Benefit Rider |
KB-MAE-AR-1301 |
|
Accident Medical Expense - Group Policy |
KB-MAE-POL-1301-0K |
|
Critical Illness - Certificate |
KB-MCI-CER-1301-0K |
|
Critical Illness - Spouse Rider |
KB-MCI-SR-1301 |
|
Critical Illness - Child(ren) Rider |
KB-MCI-CR-1301-0K |
|
Critical Illness - Group Policy |
KB-MCI-POL-1301-0K |
|
Whole Life - Certificate |
KB-MWL-CER-1301-0K |
|
Whole Life - Accidental Death Benefit Rider |
KB-MWL-ADR-1301-0K |
|
Whole Life - Chlld(ren) Term Life Benefit Rider |
KB-MWL-CTR-1301-0K |
|
Whole Life - Accelerated Death Benefit Terminal Illness Disclosure |
KB-WL-ABTIR-D-1301 |
|
Whole Life - Accelerated Death Benefit Payment Notice |
KB-WL-AB-NOT-1301 |
|
Whole Life -Group Policy |
KB-MWL-POL-1301-0K |
Liberty National Life Insurance Co.
Payroll Code: AI56
| Insurance Company Policy Type | Forms |
|---|---|
|
Group Term Paid Up at 65 |
GE65 |
|
Group Term |
GE2 |
|
Accident Protector Max |
HAJ, HAK, HAL |
|
Cancer Endurance |
5KM, KKN, 5KO |
|
Cash Center |
LCANLS-2 |
|
Career Life Plus |
8039/5148 |
Manhattan Life Assurance Company of America
Payroll Code: AI69
| Insurance Company Policy Type | Forms |
|---|---|
|
Cancer Care Plus |
CP4000OK04104 |
|
Intensive Care Rider |
1CUR 4000 |
|
Critical Care Rider |
CCBR4000OK |
|
Accident Expense |
C-ACEXP-OK |
|
Wellness Rider |
C-ACEEXWL19 |
National Teachers Associates Life Insurance Co.
Payroll Code: AI13 -- Billing Unit: National Teachers Associates Life Insurance Co.
| Insurance Company Policy Type | Forms |
|---|---|
|
Critical Illness Policy |
PO-CM-CI7001-OK (2/22) |
|
Critical Illness Outline of Coverage |
OC-CM-CI7001-OK (2/22) |
|
Cancer Rider |
RD-CM-C100 (2/22) |
|
Infectious Disease Rider |
RD-CM-ID100 (2/22) |
|
Value Rider |
RD-CM-VR100 (2/22) |
|
Return of Premium Rider |
RD-CM-ROP101 (9/23) |
|
Application for Critical Illness |
AP-CM-CI7001 (7/22) |
|
Hospital Indemnity Policy |
PO-CM-HP8002-OK (6/19) |
|
Hospital Indemnity Outline of Coverage |
OC-CM-HP8002-OK (6/19) |
|
Intensive Care Unit Rider |
RD-CM-ICU101-OK (6/19) |
|
Enhanced Hospital Indemnity Rider |
RD-CM-HP102-Z0 (6/19) |
|
Application for Hospital Indemnity |
AP-CM-HP8002-Z0 (6/19) |
|
Supplemental Application |
EF-CM-1024-Z0 (6/19) |
Providential Life Insurance Co.
Payroll Code: AI24 -- Billing Unit: Pre-Paid Legal Casualty Inc.
| Insurance Company Policy Type | Forms |
|---|---|
|
Cancer |
CC-174 |
|
Intensive Care |
IC-101 |
Security Financial Life
Payroll Code: AI49 -- Billing Unit: Assurity Life Insurance Company
| Insurance Company Policy Type | Forms |
|---|---|
|
Universal Life |
0430 OK |
Washington National Insurance Co.
(formerly Conseco Health Insurance Co.) Payroll Code: AI06 -- Billing Unit: Washington National Insurance Co.
| Insurance Company Policy Type | Forms |
|---|---|
|
Accident Secure (AD&D and Accident Insurance) |
BM000/PS1OK-A |
|
LifeChoices Series |
CH000/PS1OK-A |
|
Benefit Rider |
CH0B1/IS1ST-A |
|
Benefit Rider |
IS003/EA1OK-AA |
|
Benefit Rider |
SD090/EA1ST-A |
|
Pulse Protection (Heart & Stroke Insurance) |
KH000/PS1OK-BZ |
|
Worksite Universal Life |
CIC-3001-OK |
Contact
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Last Modified on
Nov 18, 2025
