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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 Heritage Life Insurance Co. 

Payroll Code: AI40

Insurance Company Policy Type Forms
Accident Insurance GVAP1: Approved 8/5/2002
Accident Insurance GVAPBER: ALST-126452675 No.0552
Cancer Insurance GVCP3:ALST-126107102
Critical Illness Insurance GVCIP2: ALST-126536981
Critical Illness Insurance GPCIER: ALST-128148220
Term to Age 100 Life Insurance GPTLP: MCHU-128934098

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

Central States of Omaha

Payroll Code: AI24 -- Billing Unit: Pre-Paid Legal Casualty Inc.

Insurance Company Policy Type Form
Policy C01OK (Actuary No. 1632-92-0014 only)
ICU Rider 8121OK
Policy C02OK
ICU Rider 8122OK
Return of Premium 8018
First Occurrence Rider 8119

Central United Life Insurance Co. 

Payroll Code: AI24 -- Billing Unit: Pre-Paid Legal Casualty Inc.

Insurance Company Policy Type form
Cancer Insurance Outline of Coverage FOB98OK-OC
Cancer Insurance Application AP-FOB99
Cancer Insurance Application AP-CEP99
Outline of Coverage -- Cancer OC-CP 4000 OK
Intensive Care -- Rider ICUR 4000
Critical Care -- Rider CCBR 4000
Application -- Critical Care Rider AP-CEP04-OC-OK
Outline of Coverage HDHASTOK-OC
Heart and Stroke Confinement -- Rider HRST98OK
Application -- Heart and Stroke Rider AP-HST99
Schedule -- Accident EAP-SCH
Outline of Coverage -- Accident EAP-OC-OK
Disability Income -- Rider EAP-DR-OK
Application -- Accident Rider CUL-ESAE-OK
Combined Application AP-COMBO-03

Citizens Insurance Co. 

Payroll Code: AI24 -- Billing Unit: Pre-Paid Legal Casualty Inc.

Insurance Company Policy Type form
Accidental Death ADP-781
Cancer and Dread Disease ACC-182; ACC-487-OK
Cancer and Dread Disease ACC 585-OK
Cancer 1st Occurrence Benefit Rider FOB-487
Heart Attack and Stroke HASP-487-OK
Intensive Care Unit Rider AIC-487-OK
Life GDBWL 3/83; 35PL 1/83
Return of Premium Refund Benefit Rider RPI-487

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

EMC National Life

Payroll Code: AI24 -- Billing Unit: Pre-Paid Legal Casualty, Inc.

Insurance Company Policy Type form
Cancer & Specified Disease Policy HP 9370 OK 8-99
First Occurrence Rider AMH 9372 8-99
The EMCNL Protector for Cancer HP3000

Equipoint Partners/DBA Pre Med Defender 

Payroll Code: AI68

Insurance Company Policy Type form
Group Supplemental Benefit Certificate NGSBCRT-OK 3/17

Family Heritage Life Insurance Co. 

Payroll Code: AI66 -- Billing Unit: Family Heritage Life Insurance Co.

Insurance Company Policy Type form
Cancer Care Plus Series 5 C8APP-OK/C8BR02-OK
Intensive Care Unit Rider 186V2-OK
Cardia Care Plus Series 5 H4APP-OK/H4BRO-OK
Injure Care Plus                                      ASAPP-OK/ASBR02-OK
Heritage Life Extra                                   L4APP-OK2/L4BRO-ST
Indemnicare KIAPP-OK/L6BRO-ST
Child Whole Life Insurance Protection L6APP-OK/L6BRO-ST

Humana 

Payroll Code: AI24 -- Billing Unit: Pre-Paid Legal Casualty, Inc.

Insurance Company Policy Type form
Cancer Insurance (Application) HIC-CAN-APP-OK 05/09
Cancer Insurance Policy Brochure (Outline of Coverage) HIC-OOC-OK 5/09
Intensive Care Rider HIC-ICR-OK 5/09
Payment Benefit Rider HIC-POBR-OK 5/09

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)

National Union Fire Insurance Co. of PA 

Payroll Code: AI24 -- Billing Unit: Pre-Paid Legal Casualty, Inc.

Insurance Company Policy Type form
Cancer & Specified Disease Insurance C30551NUflC
Hospital Intensive Care Rider C30553NUFIC

Occidental Life Insurance Co. 

Payroll Code: AI24 -- Billing Unit: Pre-Paid Legal Casualty Inc.

Insurance Company Policy Type form
Cancer HC3B-1 Ed. 7-86
Cancer HC2-1 Ed. 7-86
Cancer HC4-1 Ed. 7-86
Group/Franchise Disability HD1-1 Ed. 3-87
Individual/Limited Benefit-Accident HA1-1 OK Ed. 5-88
Individual/Whole Life FOH Ed. 8-86

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

Security Financial Life

Payroll Code: AI49 -- Billing Unit: Assurity Life Insurance Company

Insurance Company Policy Type form
Universal Life 0430 OK

Transamerica Life Insurance Company 

Payroll Code: AI06 -- Billing Unit: Washington National Insurance Co.

Insurance Company Policy Type form
Flexible Premium Adjustable Life Ins. Policy                CPGUL300
Flexible Premium Adjustable Life Ins. Certificate                 CCGUL300
State Amendment                 CELUL3OK
Accelerated Death Benefit for Terminal Illiness                 CRLTI100
Waiver for Layoff/Strike                 CRLWM1OK
Accelerated Death Benefit for Chronic Condition                CRLLT3OK
Extension of Benefits                 CRLEX100

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
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