Group Member Resources Group Life Insurance Group Accidental Death and Dismemberment Insurance Forms Absolute Assignment (PDF 82K)       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 107K)      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 119K)     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 114K)     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 170K)     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 95K)     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 68K)     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 69K)     This is a pre-authorized payment request form. Conversion Notice (PDF 66K)     The employer is to complete the information on this form before providing     it to the employee and/or dependent(s). Dependent Death Claim Form (PDF 108K)     When a covered dependent dies, this form is to be completed by the     employer of the insured and the designated beneficiary in order to file     a life insurance benefit.  (This is also to be used for Accidental Death.) Disability Claim Form (PDF 136K)     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 113K)     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 104K)     This form is a record of coverage, as well as designation of the      beneficiary(ies) by the employee. Evidence of Insurability Form (PDF 148K)     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.                   Group Dental Insurance 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/NCM on your DENTAL IDENTIFICATION CARD: For further information on dental insurance and to access a list of dental providers in your area, click here . You will need the FREE program, Adobe Reader (VERSION 4 OR HIGHER) to view the forms. Please click the link below to download the program.

Return to North Carolina Mutual Life