| Employee Enrollment and Change Form |
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To change a beneficiary(ies), fill out sections 4 - 6 of this form and return it to your employer.
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| Life Claim Form |
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| 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. |
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| Accidental Death Claim Form |
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| 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. |
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| Dismemberment Claim Form |
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| 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. |
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| Evidence of Insurability Form |
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| 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. |
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| Accelerated Benefits Form |
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| If applying for accelerated benefits, the member must fill out this form and submit it to Surency Life & Health. |
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| Waiver of Premium - Attending Physician's Statement |
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| If applying for waiver of premium, the attending physician must fill out this form and submit it to Surency Life & Health. |
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| Waiver of Premium - Claimant's Statement |
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| If applying for waiver of premium, the member (claimant) must fill out this form and submit it to Surency Life & Health. |
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| Waiver of Premium - Employer's Statement |
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| If applying for waiver of premium, the member's employer must fill out this form and submit it to Surency Life & Health. |
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Submit completed forms to Surency by mail:
Attn: Surency Life
P.O. Box 789773
Wichita, KS 67278-9773 |
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