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Absolute Assignment (PDF)
An employee may execute this form which gives another person the right to exercise all the privileges that the employee had under the policy.

Accelerated Benefit Claim Form (PDF )
If an insured wishes to access part of the face amount of his insurance coverage prior to death should he become terminally ill and his doctor certifies that death will occur within the indicated time period, the insured may be able to receive advance payment of life insurance proceeds.

AD&D Loss of Limb Form (PDF)
When a covered employee loses a limb as a result of an accident, this form is to be completed by the employer and the attending physician in order to file a dismemberment insurance benefit claim.

AD&D Loss of Sight Form (PDF)
When a covered employee loses sight as a result of an accident, this form is to be completed by the employer and the attending physician in order to file a dismemberment insurance benefit claim.

Attending Physician Statement Form (PDF)
This form is to accompany the Disability Claim form and is to be completed by the attending physician of the insured.

Beneficiary Change Form (PDF)
Changes to the designated beneficiary may be made after the employee?s effective date of insurance. Such changes should be recorded on this form.

Beneficiary Form (PDF)
At the time of enrollment the employee may designate anyone, other than the policyholder, as beneficiary. The employee should complete the beneficiary designation on an enrollment or beneficiary designation form. If the space provided on the form is inadequate, the employee should write ?see attached? in the space provided. He should then attach a separate signed and dated sheet of paper containing the full designation.

Check-o-matic Form (PDF)
This is a pre-authorized payment request form.

Conversion Notice (PDF)
The employer is to complete the information on this form before providing it to the employee and/or dependent(s).

Disability Claim Form (PDF)
If an employee has been totally disabled for the full length of the elimination period specified in the policy, the employee may be eligible for the Waiver of Premium benefit. Once the employee is within 20 days of completing the elimination period, the disability claim form should be submitted to us for approval. The applicable sections should be completed by the employer, the employee and the employee?s attending physician.

Employee Death Claim Form (PDF)
When a covered employee dies, this form is to be completed by the employer and the designated beneficiary in order to file a life insurance benefit. (This is also to be used for Accidental Death.)

Enrollment Form (PDF)
This form is a record of coverage, as well as designation of the beneficiary(ies) by the employee.

Evidence of Insurability Form (PDF)
This form asks questions about the current health and health history of the person proposed for insurance. This helps us to determine whether the proposed insured is insurable in accordance with our established guidelines. A separate Evidence of Insurability form must be completed for each person for whom proof is required.

Dental Insurance is provided under a Group policy issued by NC Mutual Life Insurance Company. NC Mutual Life may arrange for certain functions to be administered by external vendors.

Members with UHC Dental/NCML on your DENTAL IDENTIFICATION CARD: For further information on dental insurance and to access a list of dental providers in your area, click here