Index

Eligibility Change Form

Please complete and submit the appropriate elements for eligibility change.

General Information

* All fields are required

KCLGB ID

Email Address

Group Policy Number

Employer/Group Name

If you need assistance with your KCLGB ID# or do not know your ID#, please call 877-266-6767 (producers enter ext. 8200, employers enter ext. 8302)

Employee Information

* All fields are required

First Name

Last Name

Social Security Number

Effective Date Of Change

Select Eligibility Change Type:

Spouse Information

First Name

Last Name

Social Security Number

Gender

Date of Birth

Spouse Coverage(s)

Basic Dependent Life

Spouse Voluntary/Supplemental Life Amount:

Spouse Dental Spouse Vision

Child(ren) Information

First Name

Last Name

Date of Birth

Social Security Number

Gender

First Name

Last Name

Date of Birth

Social Security Number

Gender

First Name

Last Name

Date of Birth

Social Security Number

Gender

First Name

Last Name

Date of Birth

Social Security Number

Gender

First Name

Last Name

Date of Birth

Social Security Number

Gender

Child(ren) Coverage(s)

Basic Dependent Life

Child(ren) Voluntary/Supplemental Life Amount:

Child(ren) Dental

Child(ren) Vision

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Eligibility Change Form

General Information

* All fields are required

Employee Information

* All fields are required

Terminate an employee and all of his/her dependents

Add a new employee

It is the Employer's Responsibility to maintain a copy of the Employee Enrollment form.
If coverage is contributory and it is beyond 31 days from the first date of eligibility, a health statement must be submitted as evidence of insurability.

Employee Information

Employee Coverage (Select all that apply.)

Dependent Coverage(s) (Select all that apply): Employee Coverage Required

Selecting any of these options will display a section to enter dependent information

Change of name

Change of Insured Benefits

Spouse Information

Spouse Coverage(s)

Child(ren) Information

Child(ren) Coverage(s)

Change of address(Complete only if enrolled for Dental or Vision Coverage)

Eligibility Change Form

General Information

* All fields are required

Employee Information

* All fields are required

Terminate an employee and all of his/her dependents

Add a new employee

It is the Employer's Responsibility to maintain a copy of the Employee Enrollment form. If coverage is contributory and it is beyond 31 days from the first date of eligibility, a health statement must be submitted as evidence of insurability.

Employee Information

Employee Coverage (Select all that apply.)

Dependent Coverage(s) (Select all that apply): Employee Coverage Required

Selecting any of these options will display a section to enter dependent information

Change of name

Change of Insured Benefits

Spouse Information

Spouse Coverage(s)

Child(ren) Information

Child(ren) Coverage(s)

Change of address(Complete only if enrolled for Dental or Vision Coverage)

It is the Employer's Responsibility to maintain a copy of the Employee Enrollment form.
If coverage is contributory and it is beyond 31 days from the first date of eligibility, a health statement must be submitted as evidence of insurability.