Group Claims
Dental Claim Form
This is the standard form created by the American Dental Association. It must be completed by your Dental provider.
Critical Illness Claim Form (GG015197)
This is the standard form to be used when submitting a claim on a Guardian Critical Illness insurance policy (claims for critical illness, hospital admission, and/or wellness benefits for the policy).
Medical Claim Form (CMS-1500)
One of the most widely-used medical claims forms in the United States is CMS-1500, formerly known as HCFA-1500. In fact, many states have legislated this to be the primary claim.
Life Claim Form (GG-42)
This form consists of two sections, the claimant section, and the employer section. Both sections must be completed and signed appropriately.
Short Term Disability Claim (GG-011096)
This form consists of three sections, the claimant section, the employer section, and the physician section. All sections must be completed and signed appropriately.
Attending Physicians Statement of Disability (NRO-117)
LTD Claim (NRO-315)
Patient Protection and Affordable Care Act (PPACA)
Available for non-grandfathered health plan members at first dollar coverage, when delivered by in-network providers for plans renewing on ot after 9/23/10. (Some restrictions apply. All services or items may not be covered, such as over the counter medications and smoking deterrents.)
New York (DBL) Disability Benefits Law-Claim Form (DB450)
This New York form consists of three sections, the claimant section, the employer Section and the physician section. All three sections should be completed in full and submitted for consideration of NY State Disability (DBL) benefits. An incomplete submission may cause undue delay in the ability to make a claim determination.
Statement of Rights-Disability Benefits Law (DB271S)
This form provides a simplified presentation of your rights as required by Section 229 of the Disability Benefits Law.
New Jersey (TDB) Temporary Disability Benefits-Claim Forms (NJTDBDS1)
This form consists of three sections, the claimant section, the employer section, and the physician section. All three sections should be completed in full and submitted for consideration of NJ State Disability (TDB) benefits. An incomplete submission may cause undue delay in the ability to make a claim determination.
If you can't find the form you're looking for, login to
Guardian Anytime for additional claim forms.
If you are a Group Benefits Broker, please log onto
GuardianAnytime for any forms or materials you may need.
All other brokers or agents should contact the local Guardian General Agency to which they are affiliated.
Change of Beneficiary Form (T-94)By completing this form the beneficiary designation will be changed as indicated. Once the company receives this form, all other beneficiary documents become null and void. That means if you want any of the beneficiaries previously named to continue as your beneficiaries, you must include their names on this form.
Change of Beneficiary and Owner Form (T-95)By completing this form the owner and beneficiary designation will be changed as indicated. Once the company receives this form, all other documents pertaining to ownership and beneficiaries will be null and void. That means if you want any of the beneficiaries previously named to continue as beneficiaries, you must include their names on the form. Otherwise, the new owner will become the primary and sole beneficiary form.
Guard-O-Matic Form (R-223) By completing this form you can set up a monthly draft for premium payments or change your banking information. When setting up a draft or changing bank information, please include a voided check with your form.
Address changes can be submitted via email to
ILSA_Name_and_Address_Changes@glic.com
