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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)

Universal Life 0430 OK

 

 

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Oklahoma Office of Personnel Management
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