VPD Supplemental Insurance Policies Forms
American Family Life Assurance Co.
Payroll Code: AI03 -- Billing Unit: American Family Life Assurance Co.
| Insurance Company Policy Type | Forms |
| Accident Advantage | A-9520; A-12000 |
| Short-Term Disability | A57600OK |
| Riders: | |
| -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: | |
| -Initial Diagnosis Building Benefit Rider | B70050OK |
| -Specified-Disease Benefit Rider | B70051OK |
| -Dependent Child Rider | B70052OK |
| Hospital Confinement Indemnity – Option 1 | B40100OK |
| Riders: | |
| -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 | form |
| 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 |
| Individual Dental PPO | IDN8000-OK |
Equipoint Partners/DBA Pre Med Defender
Payroll Code: AI68
| Insurance Company Policy Type | form |
| Group Supplemental Benefit Certificate | NGSBCRT-OK 3/17 |
Kemper Benefits
Payroll Code: AI64 - -- Billing Unit: American Trustee, Inc.
| Insurance Company Policy Type | form |
| 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 Ufe - 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 | form |
| 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 | form |
| 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 | form |
| Accident Policy | GRA-3001 (1/95) |
| Cancer Policy | GRC-2004-OK (1/03) |
| Heart Disease, Heart Attack and Stroke Policy | GRH-1003-OK (10/96) |
| Disability Income Policy | GRD-6003-OK (10/99) |
| Spouse Rider - Accident | GRA-SR-OK (1/95) |
| Child Rider - Accident | GRA-CR-OK (1/95) |
| ICU Rider - Accident | GRA-ICU-OK (1/95) |
| All Purpose Impatient Rider | GR-1026-OK (2/03) |
| ICU - All Purpose Rider | GR-2015-OK (1/03) |
| Specified Disease Rider | GR-1045-OK (10/96) |
| Hospital Enhancement Rider | GR-1013-OK (8/98) |
| Benefit Booster Rider | GR-1056-OK (10/04) |
| Return of Premium Rider | GR-1082-OK (10/04) |
| ICU - Heart Only Rider | GR-1025-OK (10/96) |
| Heart Attack & Stroke First Occurrence Benefit Rider | GR-1035-OK (10/96) |
| Heart Wellness Rider | GR-1011-OK (6/98) |
| Cancer Benefit Enhancement Rider | GR-1014-OK (1/03) |
| Whole Life Insurance Policy | L-1115 (1/94) |
| Renewable & Convertible Term Life Insurance Policy | L-2225 (1/94) |
| Convertible Decreasing Term Life Insurance Policy | L-2224 (1/94) |
| Accidental Death and Dismemberment Rider | L-ADDR.70 (1/94) |
| Children's Term Insurance Rider | LCR-111 (1/94) |
| Accident Policy -- Series II | GRA-3002-OK (5/06) |
| Accident Home Recovery Benefit Rider | GR-AHRBR-OK (3/07) |
| Heart Disease, Heart Attack & Stroke Policy -- Series III | GRH-1004-OK (9/06) |
| Heart Benefit Enhancement Rider | GR-HBER-OK (10/07) |
Pre-Paid Legal Casualty, Inc.
Payroll Code: AI24 -- Billing Unit: Pre-Paid Legal Casualty Inc.
| Insurance Company Policy Type | form |
| Family Plan | PPLSI-233 |
| Law Officers Legal Plan | PPLSI-234 |
Providential Life Insurance Co.
Payroll Code: AI24 -- Billing Unit: Pre-Paid Legal Casualty Inc.
| Insurance Company Policy Type | form |
| Cancer | CC-174 |
| Intensive Care | IC-101 |
Payroll Code: AI49 -- Billing Unit: Assurity Life Insurance Company
| Insurance Company Policy Type | form |
| 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 | form |
| 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
Email: VPD@omes.ok.gov
