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Section 125 (Cafeteria Plan Administration) Forms, Information & Links

Insurance Carriers – Forms & Links

American Fidelity Assurance Company
Well Check Claim Form
Cancer Claim Form
Beneficiary Change Request
Name Change Request
Bank Draft Authorization
Address Change Form

American Public Life
Change Request Form

Assurant Employee Benefits/Union Security Ins.Co.
Assurant Disability Claim Form & Instructions
ASI Educator Service Request Form
Life Claim Statement Employee/Employer
Term Life Claim Form for Beneficiary
Assurant Term Life Beneficiary Change Form
Assurant Term Life Change Form
Voluntary Life Portability Request
Voluntary Life Conversion Request

Bay Bridge Administrators, LLC
Hartford/AIG/Nat’l Union Fire Ins. Co.
Well Check Claim Form
Cancer, Specified Disease & Intensive Care Claim Form
Service & Change Request
Bay Bridge Bank Draft Authorization

Bay Bridge Humana Cancer
REQUIREMENTS FOR CONSIDERATION
        Previous Cancer/Specified Disease/Heart History
Humana Wellness Claim Form
Humana Cancer Claim Form
Bay Bridge Bank Draft Authorization
Service & Change Request

Conseco/Jefferson National Life Ins. Co.
Cancer, Specified Disease & Intensive Care Claim Form
Cancer Bank Draft Authorization
Change Request Form
Add or Remove Family Members
HIPAA Authorization Form

Delta Dental - click here

Gerber Life
Claim Form

ING - Reliastar
Change Request Form

Reliance Standard AD&D
Change of Beneficiary
AD&D Application
ADD claim form

Texas Life
Change Forms Link

The Legend Group
Change Request Form

Transamerica
Cancer, Specified Disease & Intensive Care
        Claim Form
        Instructions
Service Change Form
Bank Draft Authorization

Vision Service Plans (VSP) – click here

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© 2002-2011 Burba Insurance Services. All rights reserved.
Brady Barham is a Registered Representatives of Legend Equities Corporation
Securities Offered Through Legend Equities Corporation, Member FINRA www.FINRA.org / SIPC www.SIPC.org.
Securities offered: Not FDIC Insured - No Bank Guarantee - May Lose Value
1096 Mechem Drive, Suite 223, Ruidoso, NM 88345, (800) 894-9990

Burba Insurance Services is not an affiliate of Legend Equities Corporation.