We don’t think legalese is very compelling to read. But where would we be without rules and regulations? Protecting your rights is our top priority; for this reason we have legalese. It’s here for the greater good.

For your convenience, all of our forms on this site are current and ready for you to print and send to us. When accessing or downloading online forms, you agree to release, indemnify and hold harmless our company and/or its subsidiaries for any damage or liability encountered from using these forms. Please remember to keep only the most current forms on file.

Privacy Forms

Authorization for Release of Protected Health Information
To be in compliance with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, a patient/guardian/personal representative must complete this form to authorize disclosure of confidential health information about any insured member. Please print and complete the form and return it to us at:

Privacy Office
P.O. Box 81889
Lincoln, NE 68510-1889
Or fax it to the Privacy Office at 402-309-2580.

English Authorization for Release of Protected Health Information
Spanish Authorization for Release of Protected Health Information

HIPAA Individual Rights Forms
Our HIPAA Privacy Notice describes member/insured’s rights with respect to the protected health information (PHI) we maintain. All requests about these rights need to be made in writing using the PHI forms.

Public Health Information Forms

Claim Forms
To submit a dental or eye care claim, all you have to do is choose the appropriate form, fill it out, sign it, and mail it to the address listed on the form.

Dental Claim Form
Eye Care Claim Form
Eye Care Exam Only Claim Form

Enrollment Forms
Getting great coverage begins with enrollment in your company’s dental and/or eye care plan. All you have to do is select one of the enrollment forms below. You have your choice of English, Spanish, High/Low, and Dual Choice.

You may use the forms to waive coverage, change names, or adding/dropping dependents. Just you choose the appropriate form, fill it out, sign it, and mail it to the address listed on the form.

English Group Enrollment/Change or Waiver Form
Spanish Group Enrollment/Change or Waiver Form
High/Low Group Enrollment/Change or Waiver Form (Please remember to Select High or Low Plan)
Spanish High/Low Group Enrollment/Change or Waiver Form (Please remember to Select High or Low Plan)
Dual Choice Group Enrollment or Waiver Form – English and Spanish (Please remember to Select Reimbursement or Prepaid Plan)

Dependent Status Forms

Exception to Dependent Child Definition
If you have a non-traditional dependent under your care, submit the form below to determine if they qualify for dependent status.

Request for Dependent Child Exception

Enroll Dependent Under Disabled Status
If your child is over the dependent age (as specified in your plan) and is considered fully disabled, please have your child's physician complete this form.

Statement of Health

COBRA Election of Insurance Continuation
If you are eligible for a continuation of dental or eye care insurance coverage complete, sign and return this form to your company's benefits representative.

Election of Insurance Continuation Form

Producer Forms
We’d love to have you join our family. But first things first: you’ll need to be licensed and appointed with us. (Some states require brokers to be pre-appointed before presenting a quote to a client.) To become appointed with us and to be compliant with HIPAA Privacy regulations, simply fill out our combined appointment application and business associate addendum. Included with the appointment application is the Direct Deposit Authorization Form, so you can have your commissions deposited directly into your bank account.

Appointment Application/Business Associate Addendum

Once you’ve completed and signed the form, mail it or fax it, along with a copy of your license, to the Group sales office nearest you.