Regulatory Forms

Click on subject matter to see listing of forms.
Women's Health and Cancer Rights Act
State Guaranty Notices
State Variations
California Language Assistance Program - Spanish Versions
(California Residents Only)

Women's Health and Cancer Rights Act

WHCRA Notice of Special Rights following Mastectomy.


State Guaranty Notices


AK - Alaska

Alaska Guaranty Notice

AR - Arkansas

Arkansas Guaranty Notice

CA - California

California Guaranty Notice

CO - Colorado

Colorado Guaranty Notice

DC - District of Columbia

District of Columbia Guaranty Notice

HI - Hawaii

Hawaii Guaranty Notice

IA - Iowa

Iowa Guaranty Notice

IL - Illinois

Illinois Guaranty Notice

IN - Indiana

Indiana Guaranty Notice

KS - Kansas

Kansas Guaranty Notice

LA - Louisiana

Louisiana Guaranty Notice

MD - Maryland

Maryland Guaranty Notice

MN - Minnesota

Minnesota Guaranty Notice

MO - Missouri

Missouri Guaranty Notice

MS - Mississippi

Mississippi Guaranty Notice

MT - Montana

Montana Guaranty Notice

NV - Nevada

Nevada Guaranty Notice

NH - New Hampshire

New Hampshire Guaranty Notice

NJ - New Jersey

New Jersey Guaranty Notice

NC - North Carolina

North Carolina Guaranty Notice

ND - North Dakota

North Dakota Guaranty Notice

NW - New Mexico

New Mexico Guaranty Notice

OH - Ohio

Ohio Guaranty Notice

OK - Oklahoma

Oklahoma Guaranty Notice

RI - Rhode Island

Rhode Island Guaranty Notice

SD - South Dakota

South Dakota Guaranty Notice

TN - Tennessee

Tennessee Guaranty Notice

TX - Texas

Texas Guaranty Notice

UT - Utah

Utah Guaranty Notice

VA - Virginia

Virginia Guaranty Notice - Must be attached to policy

WA - Washington

Washington Guaranty Notice

WV - West Virginia

West Virginia Guaranty Notice

WY - Wyoming

Wyoming Guaranty Notice


State Variations


CA - California

CAL COBRA Continuation for Medical/Dental
CA Notice of Continuation Rights for firms with 2-19 lives
CA Notice of Continuation Rights for firms with 20 or more lives.

NJ - New Jersey

NJ Mandatory Notice: Employee insurance rights under Family Leave Act (50 or more lives).


California Language Assistance Program - Spanish Versions
(California Residents Only)

Authorization for Member Initiated Request - SLHIC (U.S.)
Enrollment Request Form - SLHIC (U.S.)
CalBen COBRA Continuance of Med/Dental Form
Dental Application Non-ASO Reg.
Dental Claim Statement -SLHIC (U.S.)
Dental Enrollment Request - SLHIC (U.S.)
Dental Handout: Find a Provider
Voluntary Dental & Disability Plans Enrollment Request
Enrollment Request - SLHIC (U.S.)
Disclosure Form for Vital Documents
California Annual Notice Form
STD Handout: How to Submit a Claim Over the Telephone
Vision Claim Form - SLHIC (U.S.)
E-Z Choice Enrollment Request Application - SLHIC (U.S.)
Notice of Continuation Rights (CA) LG - SLHIC (U.S.)
Notice of Continuation Rights (CA) - SLHIC (U.S.)
Request for Continued Coverage for Handicapped Child - SLHIC (U.S.)
SLF EBG Enrollment Form with Dental