Forms Library

The list below contains all forms available for download on this website. 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.

Health Insurance Forms

Health Insurance Forms

 

Caremark Mail Order Form
Mail order form for prescription drugs
 
Group Hospital Income Insurance Dependent Coverage Form  
Dependent Coverage Form - Group Hospital Indemnity Insurance

 

Health Insurance Claim Forms and Resources

CMM Claim Form
Catastrophic Major Medical Claim Form

CMM Hospital Directory

A Directory of Hospitals in the Catastrophic Major Medical Discount Network – Admittance to a network hospital is recommended but not required by this plan.
 
Group Hospital Income Insurance Plan Claim Form
Claim Form - Group Hospital Indemnity Insurance CLAIM FILING INSTRUCTIONS Complete, date, sign and return 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 indicating the admission date, discharge date, number of days, type of room and the diagnosis.

 

Caremark Prescription Forms and Resources

Prescription Drug Claim Form
Claim Form - Prescription Drug Claim Form

Mail Order Form
 
Pharmacy Locator
 
Prescription Drug Pricing

 

Life Insurance Forms

Life Insurance Forms

Wording for Beneficiary Designations
Download and refer to this document for examples of the types of commonly requested beneficiary designations.
 
Form AMA-ASGT
Changes the beneficiary and assignment to an individual or trust agreement.
 
Form AMA-ASGT 2
Changes the assignment back to the insured.
 
Form AMA-BENE
Names an individual, corporation or partnership as beneficiary; entities can be named as primary or as contingent.
 
Form AMA-PLW
Names an individual as the primary beneficiary and the trustee designated in the last will and testament of the insured as the contingent beneficiary.
 
Form AMA-IVT
Names a trust agreement as beneficiary.
 
Form AMA-TRT
Names the trustee designated in the last will and testament of the insured as the beneficiary. 

Life Insurance Claim Forms


Life Insurance Accelerated Benefits Request Form

Accelerated Life Benefit Request 

Return completed form to:  
AMA Insurance  
330 N. Wabash Ave., Suite 39300  
Chicago, IL 60611-5885 

 
Disability Insurance Forms

Disability Insurance Forms

 

Disability Income Insurance Plan Form

Future Benefit Increase Form


Disability Claim Forms

Application for Disability Benefits

Disability Income Insurance Benefits Form

 
Office Overhead Expense Plan - Group Professional Overhead Expense Report
Expense Report - Office Overhead Expense Plan

 

Dental Insurance Forms

Dental Insurance Claim Forms

 

Dental Insurance Claim Form

Claim form for dental services

 

Additional Forms
Electronic Fund Transfer(EFT) Payment Option Form
Save time by switching to monthly automatic EFT payments. Complete this form and return it to AMA Insurance today.
 
Domestic Partnership Declaration Form

For Insureds covered in the Level Term Life, Preferred Term Life, Hospital Income, Medicare Supplement, Office Overhead Expense, Pure Term Life, Mature Decisions Life, and LIFEPace Term Life plans. 

Third Party Designee Form

Use this form to add another party to receive billing and lapse notices to help prevent unintentional lapse of insurance coverage.

 

 

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