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Automatic Premium Authorization Enrollment Form
To be completed by employers authorizing automatic payment of group benefit premium., 1 Page (Rev. 11/07)
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Broker Application for Licensing Appointment
Broker must submit with license to sell Lincoln Financial products., 2 Pages (Rev. 09/09)
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Broker EFT/Direct Deposit Authorization of Commissions Form
Broker must submit to authorize direct deposit or electronic transfer of commission payments., 1 Page (Rev. 06/08)
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Broker Fee/Override Disclosure Form
Broker must submit for each group in which an override or fee will be assessed., 2 Pages (Rev. 12/08)
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Dental Claim Form
For members submitting dental claims., 3 Pages (Rev. 05/08)
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Employee Enrollment Form for Group Insurance. Includes Waiver of Coverage.
Required of each eligible enrollee for self and dependents, whether enrolling in or waiving coverage. Use for group life, AD&D, dependent life, LTD, STD; optional employee life, optional dependent life, optional AD&D coverage., 2 Pages (Rev. 04/07)
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Employee Evidence of Insurability Form
Required of each employee or dependent enrolling in a life, AD&D, LTD, or STD plan., 4 Pages (Rev. 01/09)
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Master Application (TIP only. Under 10 employees)
Employer must complete this Participation Agreement for Small Group Insurance for groups of 10 and under. (Non-voluntary) , 7 Pages (Rev. 04/07)
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Master Application (True Group. 10+ employees.) Includes OnLine Services Registration Form
Employer must complete this master application for group insurance., 7 Pages (Rev. 04/07)
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OnLine Services Account Access Form
Employees can submit this with their insurance application to request online access to account services., 1 Page (Rev. 07/08)
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PHI Disclosure Authorization Form (Release to Employee)
Must be signed by the plan member to Jefferson Pilot to release personal & health information to the enrolled., 1 Page (Rev. 07/07)
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here or on the "Get Acrobat Reader" Image, to download the
software.
For additional information, please contact Claremont at 800.696.4543
or
info@claremontcompanies.com
