FORMS

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).

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

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.

Guide for Managing Self-Administered Plans

A reference guide overviewing employers' key administration responsibilities. Or, view our quick tutorial.

Request for Group Insurance Supplies (GG-13)

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).

Request to assign or change a beneficiary (GG-17)

Election of Continued Coverage (COBRA)GG-975

Used for terminated employees to elect federal continuation under the plan.

Coverage Management Prescription Drug Program

The latest program rules and drug listings with instructions for prior authorization.

Specialty Referral Request (Form 177-012)

Use to request a referral for special dentistry services.

Member Treatment Data Form (Form 177-014)

Use to specify type of treatment administered to patient.

Online Policy Service Request

ELECTRONIC OPTIONS AVAILABLE

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  Request a Policy Loan

  A policy loan is money that you borrow from your policy and the loan is secured by your policy. While policy loans are not contractually required to be repaid during the insured’s life, you may be required to submit a loan repayment to keep the policy in force if the loan balance exceeds your policy’s cash value. Please read the Policy Loan and Withdrawal Education Supplement beginning on page 7 of the loan form and ensure you understand the implications of taking a policy loan before submitting your loan request. 

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  Change Payment Mode

  You can change the billing frequency for premiums and/or loan interest due based on the options available with your policy. Depending on the timing of the Mode Change, additional funds may be required to pay any outstanding premiums due. Note that if you elect to pay premiums more frequently than annually, the cumulative premium in a given year will be more than if the premium is paid on an annual basis; the factors for each billing frequency type, which are used to determine the modal premium amounts, are listed in your policy.

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  Complete Tax Certification (IRS Form W-9)

  Use this form to provide your TIN, which will be used to file an information return with the IRS to report taxable gain.

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  Change Non-Forfeiture Option

  A Non-Forfeiture benefit is intended to allow the policy owner to maintain all or a portion of the policy's benefits even if the policy lapses due to the non-payment of a required premium. You can elect to proactively update the default option in case your policy lapses, or you can choose to change the policy to one of these benefits immediately if you are no longer prepared to pay policy premiums.

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  Tax Withholding Election

  Select this option to elect or change federal and state income tax withholding on your policy.

Add/Update Auto-Draft Bank Information

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. Please email your completed form to ILSolutions@glic.com or mail to The Guardian Life Insurance Co. of America, PO Box 26100, Lehigh Valley, PA 18002-6100.

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.

Guardian Index Participation Feature (IPF)

Discover the current rates for Guardian’s Index Participation Feature (IPF) – a rider that allows select Whole Life policyholders to link a portion of their paid-up-additions cash value to the performance of an index. Learn more here.

Non-Financial Service Change Form

Use this form for non-financial changes; address change, name or ownership changes, beneficiary updates, and to request a copy of your annuity contract.   

Telephone Transfer/Allocation Change Authorization Form

Use this form to establish a PIN for telephone transactions. 

Direct Deposit Authorization Form

Use this form to establish direct deposit of any withdrawals/payments from your annuity contract to a bank account. 

Income Tax Withholding Election – Annuitized Payments

Use this form to elect, change or revoke your federal and state income tax withholding election applicable to your annuitized payments.