PIC Forms

Applications

PIC Authorization to Draft Policy
PIC Reinstatement Application – Generic (for use in all other states)
PIC Reinstatement Application – Arizona
PIC Reinstatement Application – California
PIC Reinstatement Application - Colorado
PIC Reinstatement Application - Connecticut
PIC Reinstatement Application - District of Columbia
PIC Reinstatement Application - Florida
PIC Reinstatement Application – Kansas
PIC Reinstatement Application - Massachusetts
PIC Reinstatement Application - Maryland
PIC Reinstatement Application - Michigan
PIC Reinstatement Application - Minnesota
PIC Reinstatement Application - North Carolina
PIC Reinstatement Application - North Dakota
PIC Reinstatement Application – Oklahoma
PIC Reinstatement Application – Utah
PIC Reinstatement Application – Virginia
PIC Reinstatement Application - Wisconsin

Claim Forms

Disability and Death (Life only)

How to file a disability or death claim
Life claim form

Disability Claim (All coverages except Life)

Claimant’s Statement (Initial claim form; for use in all states except California)
Claimant’s Statement (Initial claim form for use by California Residents only)
Supplementary Statement of Disability (for use in all states except California)
Supplementary Statement of Disability (for use by California Residents only)

Other Forms

Surrender of Policy/Acknowledgement of Lost Policy
Request for Loan or Partial Withdrawal
Authorization to Honor Checks Drawn by PIC (Bank Draft Form)
Policyholder's Request for Change
Producer Information Form
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