LifeWise Assurance Company Home page

Arizona Forms

This page lists all the forms Insurance Producers may need to initiate enrollment or make changes to existing policies for their clients. Some of the forms on this page allow the insured or employer to complete the form online. For these forms, please complete form online, print the document, sign where required and either mail or fax it to LifeWise Assurance Company at the address/fax number on the form. You may not submit these forms to LifeWise Assurance Company electronically.

Employee Enrollment Forms

Affidavit of Domestic Partnership (.pdf)
Beneficiary Change
(.doc)
Employee Enrollment Form
(.doc)
Employee Enrollment Form - Spanish Version
(.pdf)
Evidence of Insurability - Short Form
(.doc)
Evidence of Insurability - Long Form
(.pdf)
Life Benefit Worksheet
(.doc)

Employee Claim Forms

Accelerated Benefit Form (.doc)
Accidental Loss Claim Form
(.doc)
Attending Physician's Medical Statement
(.doc)
Death Claim Form
(.doc)
Life Insurance Conversion Form
(.doc)
LTD Claim Form
(.doc)
STD Claim Form
(.doc)
Waiver of Premium
(.doc)

Employer Applications

Life/STD/LTD Group Master Application Package (.doc)
(includes Master Application, Addendum to Application and Insurance Producer of Record)

Insurance Producer of Record
(.doc)

Additional Information

Privacy Notices (.pdf)

Electronic Funds Transfer (EFT) Authorization Form (.pdf)

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