Available Forms

AVAILABLE FORMS



          
Accelerated Benefits Form
If applying for accelerated benefits, the member must fill out this form and submit it to Surency Life & Health.
   
Accidental Death Claim Form    
If loss of life occurs due to an accident, check the Accidental Death Claim box on this form and submit it, along with all necessary documentation, to Surency Life & Health. A complete list of necessary documentation is located in the Surency Life FAQ section.  
   
Conversion Packet  
If your employment is terminating and you want to learn more about converting your group term life insurance into an individual whole life policy, this document provides you with pertinent information.  
   
Conversion Application  
If applying for conversion, both you and your former employer must complete this form and submit it to Surency Life & Health.  
   
Dismemberment Claim Form 
If dismemberment occurs, submit this form along with all necessary documentation to Surency Life & Health. A complete list of necessary documentation is located in the Surency Life FAQ section. 
   
Employee Enrollment and Change Form     
To change a beneficiary(ies), fill out sections 4 - 6 of this form and return it to your employer.   
   
Evidence of Insurability Form  
In some circumstances, it is necessary to present evidence of insurability to obtain life insurance coverage. A complete list of these circumstances is located in the Surency Life FAQ section. Upon completion, submit this form to Surency Life & Health.   
   
Life Claim Form    
If loss of life occurs, submit this form along with all necessary documentation to Surency Life & Health. A complete list of necessary documentation is located in the Surency Life FAQ section.  
   
Portability of Insurance    
You may elect to continue your group term life policy through portable group life coverage, if your group offers this type of plan. This document provides you with information on how to do so.    
   
Waiver of Premium - Attending Physician's Statement    
If applying for waiver of premium, the attending physician must fill out this form and submit it to Surency Life & Health.   
   
Waiver of Premium - Claimant's Statement     
If applying for waiver of premium, the member (claimant) must fill out this form and submit it to Surency Life & Health.   
   
Waiver of Premium -  Employer's Statement     
If applying for waiver of premium, the member's employer must fill out this form and submit it to Surency Life & Health.   
   
   
Submit completed forms to Surency by mail:
Attn: Surency Life
P.O. Box 789773
Wichita, KS 67278-9773