The list below contains forms available for download for current AMA Insurance policyholders. If you have any questions about these forms, or would like AMA Insurance to mail you a form instead, please contact us

Please note that some of the forms below allow you to type information directly into the PDF, however, for privacy purposes, you may not save a filled out form.

Change a Beneficiary

Life Insurance / Accidental Death & Dismemberment (Premier Accident) Insurance

 

View examples in Wording for Beneficiary Designations of commonly requested beneficiary designations. This can assist you when filling out a beneficiary form.

Standard Change of Beneficiary Form (Form AMA-BENE)

Name an individual, corporation or partnership as beneficiary; entities can be named as primary or as contingent.

Change of Beneficiary to Trust Agreement (Form AMA-IVT)

Name a trust agreement as beneficiary.

Change of Beneficiary to Trustee Designated in the Last Will & Testament of the Insured (Form AMA-TRT)

Name the trustee designated in the last will and testament of the insured as the beneficiary.

Change of Primary Beneficiary to Individual & Contingent Beneficiary to Trustee (Form AMA-PLW)

Name an individual as the primary beneficiary and name the trustee designated in the last will and testament of the insured as the contingent beneficiary.

Change of Beneficiary & Absolute Assignment (Form AMA-ASGT)

Change the beneficiary and assignment to an individual or trust agreement.

Change of Absolute Assignment Back to Insured (Form AMA-ASGT 2)

Change the assignment back to the insured. 

File a Claim

Accidental Death & Dismemberment (Premier Accident) Insurance

 

To start your claim, please contact Customer Care at 1-888-627-5883 (8 am – 5 pm CT, Monday – Friday).

 

Dental Insurance

 

Dental Insurance Claim Form

File a claim for dental services.

 

Disability Insurance

 

Disability Insurance Claim Form

Submit this form to file a claim.

 

Hospital Income (Hospital Indemnity) Insurance Plan

 
Hospital Income (Hospital Indemnity) Insurance Form
In order to file a claim, complete, date, sign and return this form with one of the following:
  • A UB-04 form issued by the hospital
  • An itemized hospital bill, along with a diagnosis provided by your attending physician. A balance due statement is not acceptable.
  • A statement from the hospital indicated the admission date, discharge date, number of days, type of room and diagnosis.

 

Catastrophic Major Medical/Excess Major Medical Insurance

 

Catastrophic Major Medical Claim Form

File a claim for Catastrophic Major Medical insurance.

 

Life Insurance

 

To report the death of an insured and begin the claims process, please contact Customer Care at 1-888-627-5883 (8 am – 5 pm CT, Monday – Friday).

To file a Waiver of Premium Claim, please complete the Waiver of Premium Claim FormIf you are disabled and have elected the Waiver of Premium Rider, please return the completed form to:
AMA Insurance
330 N. Wabash Ave., Suite 39300  
Chicago, IL 60611-5885 

To file for an Accelerated Life Insurance Benefit, please complete the Accelerated Life Benefit Request Form. You can request an Accelerated Life Benefit payment if insured is terminally ill with a life expectancy of 12 months or less. Please return the completed form to:  
AMA Insurance
330 N. Wabash Ave., Suite 39300  
Chicago, IL 60611-5885 

 

Long Term Care Insurance

 

To start your claim for Long Term Care Insurance issued by Hartford Life Insurance and UNUM (Provident), please contact Customer Care at 1-888-627-5883 (8 am – 5 pm CT, Monday – Friday).

 

Office Overhead Expense Insurance

 

Office Overhead Expense Claim Form
Submit this form to file a claim. 

IMPORTANT: As part of the claims process, please complete the Group Professional Overhead Expense Record Form.

Other Insurance Plans

 

If you don't see your plan listed above, please contact Customer Care at 1-888-627-5883 (8 am – 5 pm CT, Monday – Friday) for assistance in filing a claim.

Add Dependents

Hospital Income (Hospital Indemnity) Insurance Plan

 
Hospital Income (Hospital Indemnity) Dependent Enrollment Form
Add dependent(s) to your coverage.
Change Billing Information

Automatic Payments

 
Electronic Fund Transfer (EFT) Enrollment Form
Enroll in EFT to setup automatic monthly payments from your bank account.


Add Secondary Address

 
Add Secondary Address Form

Add another address/individual to your account. They will receive a copy of billing and lapse notices to help prevent unintentional lapse of insurance coverage.

Helpful Resources
Wording for Beneficiary Designations

View examples of commonly requested beneficiary designations, which can assist you when filling out a change of beneficiary form.

Catastrophic Major Medical Insurance Hospital Directory

View the directory of hospitals in the CMM plan. Admittance to a network hospital is recommended but not required by this plan.

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