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Policy
Change Forms
Please note: The Health Insurance Portability and
Accountability Act (HIPAA) Authorization form (L-3100)
must be submitted with your policy change/reinstatement request.
Policy Conversions - click on the name of the state of your
current residence to obtain the proper form.
For All Other Policy Changes - click on the name of the state that
the policy was issued in to obtain the proper form.
All other states - click here.
*For all products except: BR®-1O,
15, 20, 30; GR®-20; BRxsm-1O, 15, 20, 30; GRxsm-1O,
15, 20, 30
**For the following products: BR®-1O, 15, 20, 30; GR®-20;
BRxsm-1O, 15, 20, 30; GRxsm-1O, 15, 20, 30
Reinstatement Forms
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For
New York - click here - HIPAA Authorization form
All
other states - click here - HIPAA Authorization form
Click on the name of the state that the policy was issued in to obtain
the proper form.
All other states - click here.
+For
reinstatements that have been lapsed for more than 90 days, a
Statement of Health form must also be completed.
*For all products except BR®-10,
15, 20, 30; GR®-20; BRxsm-10, 15, 20, 30; GRxsm-1O,
15, 20, 30
**For the following products: BR®10, 15, 20, 30; GR®-20;
BRxsm-l0, 15, 20, 30; GRxsm-1O, 15, 20, 30
Statement of Health Forms
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All other states - click here.
+Required
for all reinstatements that have been lasped for more than 90 days.
*For all products except: BR® -10, 15, 20, 30;
GR®-10; BRxsm -10, 15, 20, 30; GRxsm-10,
15, 20, 30
**For the following products: BR®-10, 15, 20, 30; GR®-20;
BRxsm-10, 15, 20, 30; GRxsm-10, 15, 20, 30
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