Supplemental Insurance Policies
INSURANCE COMPANY
POLICY TYPE |
FORMS |
5 Star Life Insurance Company (pay to 5 Star Life Insurance Company)
(Payroll Code: AI42 -- Billing Unit: 5 Star Insurance Company)
| Family Protection Plan Term to Age 100 with Critical Illness |
WS-UT100OK |
| Family Protection Plan Term to Age 100 with Terminal Illness |
FPP-TI-OK |
| 5 Star Executive Level Plan |
ILT200 |
5 Star Life Insurance Company (pay to Insurance Network Agency)
(Payroll Code: AI54 -- Billing Unit: Insurance Network Agency, Inc.)
| Family Protection Plan Term to Age 100 with Critical Illness |
WS-UT100OK |
| Family Protection Plan Term to Age 100 with Terminal Illness |
FPP-TI-OK |
| 5 Star Executive Level Plan |
ILT200 |
American Family Life Assurance Company
(Payroll Code: AI03 -- Billing Unit: American Family Life Assurance Company)
| Cancer |
A-9520; A-12000 |
| First-Occurrence Building Benefit |
A-70250 |
| Hospital Intensive Care |
A-9990 |
| Life |
5191 |
| Life Assurance |
A-62100-OK, A-62200-OK |
| Rider Series |
A-62250, A-62055-OK, A-62050, A-62051 |
| Personal Accident Expense Plan |
A33000 |
| Personal Accident Expense Plan |
A-33005OK |
| Personal Accident Indemnity Plan |
A-34100-OK, A-34200-OK |
| Optional Off-the-Job Accident Disability Rider |
A-34050-OK |
| Optional Sickness Disability Rider |
A-34052-OK |
| Optional Spouse Off-the-Job Accident Disability |
A-34053-OK |
| Personal Cancer Protector Plan |
A-59000 |
| First-Occurrence Building Benefit Rider |
A-59050 |
| Specified Disease Benefit Rider |
A-59052-OK |
| Personal Hospital Intensive Care |
A-1820B-OK |
| Personal Disability Income Protector |
A-57400-OK |
| 3 month Limited Benefit |
A-574LB-OK |
| Personal Disability and Income Protector |
A-57000-OK |
| Personal Accident Indemnity Plan |
A-34001-OK |
| Personal Long-Term Care Plan |
A-27000-OK |
| Long-Term Care Inflation Rider |
A-27062 |
| NonForfeiture Benefit Rider |
A-27051 |
| Personal Recovery Plus (Specified Event) |
A-70200 |
| First-Occurrence Building Benefit |
A-070250 |
| Personal Sickness Indemnity Plan |
A-45100, A-45200-OK, A-45300-OK |
| Optional Initial Hospitalization Benefit Rider |
A-45050 |
| Voluntary Indemnity Plan |
A-442200-OK |
| Initial Hospitalization Benefit Rider |
A-44150, A-44250 |
American General Life Insurance Company
(Payroll Code: AI36 -- Billing Unit: American General Life Insurance Company)
| Accidental Death Benefit |
88012 |
| Certificate Application |
LD 8239-5G |
| Certificate Endorsement |
L 4412 |
| Children's Insurance Benefit |
88420 |
| Family Insurance Benefit |
88419 |
| Future Guaranteed Insurability Rider |
95101 |
| Group Flexible Premium Adjustable Life Insurance Certificate |
88450 |
| Group Master Plan |
88451 |
| Group Master Plan |
92463 |
| Level Term Life Insurance Benefit on the Spouse of the Insured |
91417 |
| Master Policy Application |
L 4411 |
| Term Life Insurance Benefit on the Spouse of the Insured |
88389 |
| Waiver of Monthly Deduction |
88011 |
| Children's Insurance Benefit |
82410 |
| Waiver of Monthly Deduction |
82001 |
| Terminal Illness Rider (Group Master Plan or Estate Master Select) |
91401 |
| Loss of Independent Living Rider |
04805 |
| Accidental Death and Dismemberment Rider |
04022 |
| Hospital Cash Rider |
04025 |
| AIG CriticalCare |
03800-37 Rev 0105 |
| AIG EmergencyCare |
04120-37 |
| Accident-Only Short-Term Disability Rider (Off the Job) |
04023-37 |
| AIG CancerCare Platinum Plus |
02183 |
| AIG Worksite Universal Life |
08463 |
American Heritage Life Insurance (pay to American Heritage Life Insurance)
(Payroll Code: AI40 -- Billing Unit: American Heritage Life Company)
| Accidental Death and Dismemberment Policy |
AP2 |
| Accidental Death and Dismemberment Policy (Off the Job Coverage) |
AP3 |
| AHLminimedicalø |
G-3000(OK)-P |
| Cancer and Specified Disease Expense Policy |
CP10 |
| Critical Illness Policy |
CILP1OK |
| Dental Heritage Choice |
G-DEN-P |
| Disability Income Policy |
DI5WOK |
| Flexible Premium Adjustable Life Insurance Policy |
Ul9POK / UL10POK / UL11POK |
| Group Accident |
GVAP1(OK) |
| Group Cancer Policy |
GVCP2 |
| Group Voluntary Disability Policy |
GVD-4000FOKP |
| Group Voluntary Life Policy |
GVL-4000POK |
| Heart Attack, Heart Disease and Stroke Policy |
HSP2OK |
American Heritage Life Insurance (pay to Insurance Network Agency, Inc.)
(Payroll Code: AI54 -- Billing Unit: Insurance Network Agency, Inc.)
| Accidental Death and Dismemberment Policy |
AP2 |
| Accidental Death and Dismemberment Policy (Off the Job Coverage) |
AP3 |
| AHLminimedicalø |
G-3000(OK)-P |
| Cancer and Specified Disease Expense Policy |
CP10 |
| Critical Illness Policy |
CILP1OK |
| Dental Heritage Choice |
G-DEN-P |
| Disability Income Policy |
DI5WOK |
| Flexible Premium Adjustable Life Insurance Policy |
Ul9POK / UL10POK / UL11POK |
| Group Accident |
GVAP1(OK) |
| Group Cancer Policy |
GVCP2 |
| Group Voluntary Disability Policy |
GVD-4000FOKP |
| Group Voluntary Life Policy |
GVL-4000POK |
| Heart Attack, Heart Disease and Stroke Policy |
HSP2OK |
| Horizon 20 Year Term |
P20RCT |
American Public Life Insurance Company
(Payroll Code: AI05 -- Billing Unit: American Public Life Insurance Company)
| Accident Expense, Death and Dismemberment |
A-2 (3/80) |
| Cancer and Specified Disease |
S-CSD-1 (6/83) |
| Cancer and Specified Disease |
BDCPA (7/83) |
| Cancer and Specified Disease |
APL-1 (6/86) |
| Cancer and Specified Disease |
GCPW (6/86) |
| Cancer and Specified Disease |
APLIC-1 (10/90) |
| Cancer and Specified Disease |
APLIC-2 (10/90) |
| Cancer and Specified Disease |
APLIC-3 (10/90) |
| Convertible Term Life/Decr. Term |
S-900 (1/89) |
| Hospital Intensive Care/Coronary Care |
IC-CC-1 (Rev. 8/82) |
| Hospital Intensive Care/Coronary Care |
IC-CC-2 (6/86) |
| Heart Attack/Stroke |
HA/S-1 (6/86) |
| Intensive Care/Coronary Care |
IC/CC-3 (2/90) |
| Whole Life |
WL-1 (11/86) |
Assurity Life Insurance Company
(Payroll Code: AI 49 -- Billing Unit: Assurity Life Insurance Company)
| Return of Premium Rider |
CIR018 |
| Disability Waiver |
CIR016 |
| Automatic Benefit Increase |
A-DR205 |
| Return of Premium Rider |
A-DR208 |
| Residual Benefit Rider |
R-D220 |
| Guaranteed Insurability Rider |
RD221 |
| Hospital Benefit Rider |
A-DR202 |
| Home Modification Rider |
A-DR210 |
| Retroactive Injury Benefit |
RD222 |
| Critical Illness |
CI005 (OK) |
| Accidental Death Benefit |
A-R126 (OK) |
| Spouse Rider |
CIR-010 (OK) |
| Dependent Child Rider |
CIR014 (OK) |
| Critical Illness |
CI007 (OK) |
| Spouse Rider |
CIR012 (OK) |
| Children's Rider |
CIR020 (OK) |
| Personal Disability |
A-D100 (OK) |
| Supplemental DI Rider |
A-DR200 (9/95) |
| Simplified Life |
A-LN00 (OK) |
| Accident Expense Policy |
AAW-A117OK |
| Family Rider |
AAW-AR260OK |
| Outpatient Sickness |
AAW-DR225OK |
| Intensive Care Benefit |
AAW-DR226OK |
| Private Duty Nurse |
AAW-DR227OK |
| Surgical and Anesthesia and Additional Benefits |
AAW-DR228OK |
| Surgical Anesthesia and Additional Benefits |
AAW-DR230OK |
| Disability Income Policy |
AAW-D113OK |
| Sickness Benefits |
AAW-DR220N0 |
| Emergency Accident |
AAW-DR221 |
| Accidental Death and Dismemberment |
AAW-DR222 |
| Cancer Expense |
AAW-C120 OK |
| Cancer Expense Rider |
AAW-CR261 OK |
| Cancer Expense Rider |
AAW-CR262 OK |
| Cancer Expense Rider |
AAW-CR263 OK |
| Cancer Expense Rider |
AAW-CR264 OK |
| Accident Expense |
W A200 OK |
| Accident Expense (Off the Job) |
W A205 OK |
| Short Term Disability Income Rider |
R WA201 OK |
| Short Term Disability Income Rider (Off the Job) |
R WA251 OK |
Central States of Omaha
(Payroll Code: AI24 -- Billing Unit: Pre-Paid Legal Casualty Inc.)
| Policy |
C01OK (Actuary No. 1632-92-0014 only) |
| ICU Rider |
8121OK |
| Policy |
C02OK |
| ICU Rider |
8122OK |
| Return of Premium |
8018 |
| First Occurrence Rider |
8119 |
Citizens Insurance Company
(Payroll Code: AI24 -- Billing Unit: Pre-Paid Legal Casualty Inc.)
| Accidental Death |
ADP-781 |
| Cancer and Dread Disease |
ACC-182; ACC-487-OK |
| Cancer and Dread Disease |
ACC 585-OK |
| Cancer 1st Occurrence Benefit Rider |
FOB-487 |
| Heart Attack and Stroke |
HASP-487-OK |
| Intensive Care Unit Rider |
AIC-487-OK |
| Life |
GDBWL 3/83; 35PL 1/83 |
| Return of Premium Refund Benefit Rider |
RPI-487 |
Columbian Life Insurance Company
(Payroll Code: AI50 -- Billing Unit: Columbian Life Insurance Company)
| 20 Year Level Term -- Critical Life |
1F559B-CL |
| Accelerated Benefit Rider-Critical Illness to Age 85 |
1H803P-CL |
| Payro Waiver of Premium Rider |
1H805B-CL |
| Waiver of Premium Rider |
1H800B-CL |
| Accidental Death of Insured before Age 70 Rider |
1H801-CL |
| Automatic Increase Rider |
1H804-CL |
| Child Term Insurance Rider |
1H802-CL |
| Universal Life Certificate |
9F133H-CL |
| Waiver of Monthly Deduction Rider |
9CC02-CL |
| Child Term Insurance Rider |
9C402B-CL |
Conseco Health Insurance Company (formerly Capitol American Life Insurance Co.)
(Payroll Code: AI06 -- Billing Unit: Conseco Health Insurance Company)
| Accident Secure (AD&D and Accident Insurance) |
BM000/PS1OK-A |
| LifeChoices Series |
CH000/PS1OK-A |
| Benefit Rider |
CH0B1/IS1ST-A |
| Benefit Rider |
IS003/EA1OK-AA |
| Benefit Rider |
SD090/EA1ST-A |
| Pulse Protection (Heart & Stroke Insurance) |
KH000/PS1OK-BZ |
| Worksite Universal Life |
CIC-3001-OK |
EMC National Life (pay to Pre-Paid Legal Casualty, Inc.)
(Payroll Code: AI24 -- Billing Unit: Pre-Paid Legal Casualty, Inc.)
| Cancer & Specified Disease Policy |
HP 9370 OK 8-99 |
| First Occurrence Rider |
AMH 9372 8-99 |
| The EMCNL Protector for Cancer |
HP3000 |
EMC National Life (pay to Insurance Network Agency, Inc.)
(Payroll Code: AI54 -- Billing Unit: Insurance Network Agency, Inc.)
| Worksite IWL (Increasing Whole Life) |
|
| Whole Life Policy |
EAP002 OK |
| Accelerated Death Benefit Rider |
ELR246 |
| Term Insurance Rider for Children |
ELR242 |
| Worksite CI (Critical Illness) |
|
| Ten Year Renewable Term Policy |
LP750 OK |
| Accelerated Benefit Rider |
LP751 OK |
| Term Insurance Rider for Children |
LP753 |
| Accelerated Benefit Rider for Children |
LP754 OK |
| Critical Illness Life Insurance Application |
EAP756 OK |
| Disclosure -- Accelerated Benefit Rider |
EUN752 OK |
Great American Life Insurance Company (pay to Insurance Network Agency, Inc.)
(Payroll Code: AI54 -- Billing Unit: Insurance Network Agency, Inc.)
| Long Term Care Policy |
4LTCIP0001-OK |
| Accelerated Payment of Premium Rider |
4LTCIE0001-ACC |
| Prescription Drug Benefit in a Nursing Home |
4LTCIE0001-PDNH |
| Enhanced Nursing Home Care Rider |
4LTCIE0001-ENH |
| Enhanced Home Health Care Rider |
4LTCIE0001-EHHC |
| Monthly Home Care Benefit Rider |
4LTCIE0001-MHC |
| Full Restoration of Benefits Rider |
4LTCIE0001-FROB |
| Joint Coverage Rider |
4LTCIE0001-JC |
| Dual Waiver of Premium Rider |
4LTCIE0001-DWP |
| Simple Benefit Increase Rider |
4LTCIE0001-SBIO |
| Compound Benefit Increase Rider |
4LTCIE0001-CBIO |
| Delayed to Age 65 Compound Benefit Increase Rider |
4LTCIE0001-DBIO |
| Guaranteed Purchase Option Rider |
4LTCIE0001-GPO |
| Full Return of Premium Benefit Rider |
4LTCIE0001-FROP |
| Return of Premium Benefit Rider |
4LTCIE0001-ROP |
| Graded Return of Premium Benefit Rider |
4LTCIE0001-GROP |
| Nonforfeiture Benefit – Shortened Benefit Period Rider |
4LTCIE0001-NFB |
| 80/20 Coinsurance Rider |
4LTCIE0001-COIN |
| Full Survivorship Paid Up Benefit Rider |
4LTCIE0001-FSWP |
| Survivorship Paid Up Benefit Rider |
4LTCIE0001-SWP10 |
| Waiver of Elimination Period for Home Care, Adult Day Care & Monthly Cash Benefit Alternative Rider |
4LTCIE0001-WEP |
| Single Premium Payment Amendatory Rider |
4LTCIE0001-SP |
| 5 Year Premium Payment Amendatory Rider |
4LTCIE0001-5PAY |
| 10 Year Premium Payment Amendatory Rider |
4LTCIE0001-10PAY |
| 15 Year Premium Payment Amendatory Rider |
4LTCIE0001-15PAY |
| 20 Year Premium Payment Amendatory Rider |
4LTCIE0001-20PAY |
| Paid Up at Age 65 Premium Payment Amendatory Rider |
4LTCIE0001-PU65 |
GuaranteeTrust Life Insurance Company
(Payroll Code: AI55 -- Billing Unit: Guarantee Trust Life Insurance Company)
| Accident Only Policy -- includes limited benefits for disability income |
G0760 |
| Cancer Plan |
G0330 (OK) |
Leaders Life Insurance Company
(Payroll Code: AI29 -- Billing Unit: Leaders Life Insurance Company)
| LifeStyle Plan |
LL.17.1 |
| Term to 100 |
LL-3 |
| 10 & 15 Year Term |
LL10.15 |
MedAmerica Insurance Company
(Payroll Code: AI54 -- Billing Unit: Insurance Network Agency, Inc.)
| Simplicityii Long Term Care Insurance Policy (Tax-Qualified) |
SPL2-336-OK |
| Policy Schedule Page (Located within the Policy) |
SPL2-238-OK |
| Community Only Rider |
S2-COMMR-OK |
| Facility Only Rider |
S2-FACR-OK |
| Shared Care Rider |
S2-SCR-OK |
| Shared Waiver Rider |
S2-SWR-OK |
| Survivor Benefit Rider |
S2-SVR-OK |
| Return of Premium Rider |
S2-ROPR-OK |
| Full Return of Premium Rider |
S2-FROPR-OK |
| Restoration of Benefits Rider |
S2-ROBR-OK |
| Shortened Benefit Period Rider |
S2-SBPR-OK |
| Simple Benefit Increase Rider |
S2-SBIR-OK |
| Compound -- 2X Maximum Rider |
S2-CMP2X-OK |
| Compound -- No Maximum Rider |
S2-CMP-OK |
| Outline of Coverage |
S2-151-OK |
| Coverage Change Form (within 30 days) |
S2-15830-OK |
| Application -- Individual and Affiliation |
S2-345-OK |
| Application -- Employer Program |
S2-346-OK |
| Replacement Form (Insurer Copy) |
S2-150 |
| Replacement Form (Applicant Copy) |
S2-150A |
| Conditional Receipt |
S2-103 |
| Personal Worksheet |
200 |
| Things You Should Know |
202 |
| Suitability Letter A |
200A |
| Suitability Letter B |
200B |
| Suitability Instructions |
200I |
| Suitability Standards |
200S |
National Teachers Associates Life Insurance Company
(Payroll Code: AI13 -- Billing Unit: National Teachers Associates Life Insurance Company)
| Accident Policy |
GRA-3001 (1/95) |
| Cancer Policy |
GRC-2004-OK (1/03) |
| Heart Disease, Heart Attack and Stroke Policy |
GRH-1003-OK (10/96) |
| Disability Income Policy |
GRD-6003-OK (10/99) |
| Spouse Rider - Accident |
GRA-SR-OK (1/95) |
| Child Rider - Accident |
GRA-CR-OK (1/95) |
| ICU Rider - Accident |
GRA-ICU-OK (1/95) |
| All Purpose Impatient Rider |
GR-1026-OK (2/03) |
| ICU - All Purpose Rider |
GR-2015-OK (1/03) |
| Specified Disease Rider |
GR-1045-OK (10/96) |
| Hospital Enhancement Rider |
GR-1013-OK (8/98) |
| Benefit Booster Rider |
GR-1056-OK (10/04) |
| Return of Premium Rider |
GR-1082-OK (10/04) |
| ICU - Heart Only Rider |
GR-1025-OK (10/96) |
| Heart Attack & Stroke First Occurrence Benefit Rider |
GR-1035-OK (10/96) |
| Heart Wellness Rider |
GR-1011-OK (6/98) |
| Cancer Benefit Enhancement Rider |
GR-1014-OK (1/03) |
| Whole Life Insurance Policy |
L-1115 (1/94) |
| Renewable & Convertible Term Life Insurance Policy |
L-2225 (1/94) |
| Convertible Decreasing Term Life Insurance Policy |
L-2224 (1/94) |
| Accidental Death and Dismemberment Rider |
L-ADDR.70 (1/94) |
| Children's Term Insurance Rider |
LCR-111 (1/94) |
| Accident Policy -- Series II |
GRA-3002-OK (5/06) |
| Accident Home Recovery Benefit Rider |
GR-AHRBR-OK (3/07) |
| Heart Disease, Heart Attack & Stroke Policy -- Series III |
GRH-1004-OK (9/06) |
| Heart Benefit Enhancement Rider |
GR-HBER-OK (10/07) |
National Union Fire Insurance Company of PA
(Payroll Code: AI24 -- Billing Unit: Pre-Paid Legal Casualty, Inc.)
| Cancer & Specified Disease Insurance |
C30551NUflC |
| Hospital Intensive Care Rider |
C30553NUFIC |
Occidental Life Insurance Company
(Payroll Code: AI24 -- Billing Unit: Pre-Paid Legal Casualty Inc.)
| Cancer |
HC3B-1 Ed. 7-86 |
| Cancer |
HC2-1 Ed. 7-86 |
| Cancer |
HC4-1 Ed. 7-86 |
| Group/Franchise Disability |
HD1-1 Ed. 3-87 |
| Individual/Limited Benefit-Accident |
HA1-1 OK Ed. 5-88 |
| Individual/Whole Life |
FOH Ed. 8-86 |
Pre-Paid Legal Casualty, Inc
(Payroll Code: AI24 -- Billing Unit: Pre-Paid Legal Casualty Inc.)
| Family Plan |
PPLSI-233 |
| Law Officers Legal Plan |
PPLSI-234 |
Providential Life Insurance Company
(Payroll Code: AI24 -- Billing Unit: Pre-Paid Legal Casualty Inc.)
| Cancer |
CC-174 |
| Intensive Care |
IC-101 |
Security Financial Life
(Payroll Code: AI49 -- Billing Unit: Assurity Life Insurance Company)
Copyright 2005, All Rights Reserved
Oklahoma Office of Personnel Management
DISCLAIMER
