Group Claims Dental Claim FormThis 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.
LTD Claim Packet
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.
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.
Title Form (016256)
By completing this form the name, owner, or beneficiary designation will be changed as indicated. Once the company receives this form, all other documents pertaining to name, ownership and beneficiaries will be 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.
Trust Certification
This form should be used for all new business cases in which a trust will own the policy and in situations when an in force policy ownership change involves a trust. The form provides additional information and clarity regarding the trust and the signing authority of the trustees and in many cases will eliminate the need for you to provide a copy of the trust documents for review. However, there are certain circumstances in which Guardian will still also require the Trust documents, including, but not limited to, the following: (1) Pension Trust Cases, (2) Premium Financing Cases, (3) Cases involving Captive Insurance Companies and (4) Any application on an insured age 70 or more and the total face amount applied for is $1,000,000 or more.
Address changes can be submitted via email to
ILSA_Name_and_Address_Changes@glic.com. Name change requests may be submitted using the Title Form (016256) that appears above.
