Neptune-Administered General Forms

The forms listed below are for use in states that do not require state-specific forms. For state-specific forms, click "By State" and select the applicable state. Important: Many states require state-specific forms to be used when applying for coverage. Please check state-specific forms prior to downloading any general forms.

Administration Back To Top

Group Insurance Plans

.  Neptune Administered State EOI Guide

The United States Life Insurance Company

. 00302101-1113USL Group Employee Enrollment Form
. 00302201-1020USL Refusal of Insurance Card
. 00302201-1141USL Request for Change of Beneficiary/Name Change
. 00302201-1027USL Acknowledgement/Election of COBRA Continuation Right
.06673221-1005USL Reporting Summary
. 06673221-1062USL Request a Quote for Conversion of Group Term Life to Individual Whole Life
. 00302101-1057USL Reporting Summary--For Reporting Changes and Terminations
. 00850006-2984USL Pay Your Premiums Using Electronic Funds Transfer
. AGLC100023USL Group Order Form--Employee Certificates
. 00302301-1006USL Application to Reinstate Group Insurance
. 00305601-1612USL Absolute Assignment

American General Life Insurance Company of Delaware

.06670220-1183USL Master Application
.06670220-3461USL New Case Submission Check List
.06673221-1005AGLCD Reporting Summary
. 06673221-1009USL Group Employee Enrollment Form
. 06673221-1020USL Refusal of Insurance Card
. 06673221-1019USL Request for Change of Beneficiary/Name Change
. 06673221-1004USL Acknowledgement/Election of COBRA Continuation Right
. 06673221-1062USL Request a Quote for Conversion of Group Term Life to Individual Whole Life
. 06673221-1005USL Reporting Summary--For Reporting Changes and Terminations
. 00850006-2984USL Pay Your Premiums Using Electronic Funds Transfer
. AGLC100023USL Group Order Form--Employee Certificates
. 06673221-1012USL Application to Reinstate Group Insurance
. 06673221-1013USL Absolute Assignment 
. 06673221-1049USL Certificate of Domestic Partnership  
. American General Benefit Solutions Letterhead Template
.06673004-1001 Administrator Due Diligence Questionnaire

Group Insurance Manuals

. GHOAM Plan Administrator's Guide--Home Office Billed Groups
. GSAM Plan Administrator's Guide--Self Administered Groups

Voluntary Insurance Plans

The United States Life Insurance Company

. 00305601-1167AUSL Request for Conversion to a Group Term Life Insurance Plan
. 00302201-1143USL Group Insurance Self-Accounting Premium Statement for Vol Life AD&D Dependent Child
. 00302201-1144USL Group Insurance Self-Accounting Premium Statement STD & LTD Only
. 00302201-1141USL Request for Change of Beneficiary/Name Change
. 00305601-1084USL Request to Add Newborn Dependent Children
. 00302301-1006USL Application to Reinstate Group Insurance
. 00305601-1612USL Absolute Assignment

American General Life Insurance Company of Delaware

. 06673221-1006USL Request for Portability to a Group Term Life Insurance Plan
. 06673221-1019USL Request for Change of Beneficiary/Name Change
. 06673221-1008USL Request to Add Newborn Dependent Children
. 06673221-1012USL Application to Reinstate Group Insurance
. 06673221-1013USL Absolute Assignment

Voluntary Insurance Manuals

. VHOAM Voluntary Home Office Administration Manual
. VSAM Voluntary Self Administration Manual

Claims Back To Top

Dental

. 00303401-1132USL Dental Claim Form
. 00302201-1087USL Delta Dental Plan of New Jersey
. 00303401-1134USL Annual Family Profile Form

Disability

. 06673412-9006 Disability Claim Form

Waiver of Premium

For initital claim complete and submit all three forms below.
. 00304201-1020USL Claimant's Statement
. 00304201-1021USL Employer's Statement
. 00304201-1022USL Attending Physician's Statement

For continuing claims complete and submit the following.
. 00304201-1040USL Continuance of Total Disability
. 00304201-1041USL Attending Physician's Statement

Life

. 00304201-1079USL Proof of Group Death Claim Form
. 00304201-1015USL Proof of Group Death Claim Form--Dependent Life 
. ACCREQUSL AG Life Accelerated Group Life Benefits
. 00304201-1086USL Proof of Accidental Injury, Dismemberment

Vision

. 06675006-1028 Out-of-Network Claim Form

Group Statement of Insurability Back To Top

The United States Life Insurance Company

. 00305101-1013USL Statement of Insurability for Group Insurance

American General Life Insurance Company of Delaware

. 06673571-1005USL Statement of Insurability for Group Programs

Voluntary Statement of Insurability Back To Top

The United States Life Insurance Company

. 00305101-1098USL Application for Group Voluntary Programs All Coverages

American General Life Insurance Company of Delaware

. 06673571-1098USL Application for Group Voluntary Programs All Coverages 
. 06673571-1496USL Application for Group Voluntary Programs Life & AD&D Only