Welcome to Insurance Coordinators of Montana, Inc.

Insurance Coordinators of Montana, Inc.

Listed below are the basic forms for all of our carriers. If you do not find the form required in the list below please visit the carrier website (found under Business Partners) or call Insurance Coordinators for further assistance.

Assurity
Delta Dental
Dental Network of America (DNOA)
Fort Dearborn Life Insurance
Mountain Vision
The Benefit Group
United Heritage
Unum
USAble Life
VSP

Assurity

Employee Enrollment Form (Not Available Online-Call Insurance Coordinators)

Employer Guarantee to Issue Application

Policy Change Form

Delta Dental

Employee Enrollment Form

Request for Proposal (RFP)

HIPAA Employer Enrollment Form (required)

DNOA

Employer Application (MT)

Employer Application (ID)

Employer Application (OR, WY)

Employer Application (WA)

Employee Enrollment Form (MT)

Employee Enrollment Form (ID)

Employee Enrollment Form (OR, WA, WY)

Frequently Asked Questions

Membership Change Form

Fort Dearborn Life

Employer Life/AD&D/STD Application (MT, OR, WY)

Employer Life/AD&D/STD Application (ID)

Employer Life/AD&D/STD Application (WA)

Employer LTD Application

Employer Group Products Combined Application (ID, OR, WA, WY)

Employer Voluntary Products Application (MT, WY)

Employer Voluntary Products Application (ID)

Employer Voluntary Products Application (OR)

Employer Voluntary Products Combined Application (ID)

Employer Voluntary Products Application (WA)

Employer Voluntary Products Application (WY)

Employee Enrollment Form - All Products (MT, OR, WY)

Employee Enrollment Form - All Products (ID)

Employee Enrollment Form - All Products (WA)

Evidence of Insurability Application

BCBS/FDL Small Group Life Contract

EAWM Employer Contract

Membership Change Form

Rx Advantage Employer Sponsor Form

Conversion Form (MT)

Conversion Form (ID)

Conversion Form (OR, WA, WY)

Portability Application (MT, ID, OR, WY)

Portability Application (WA)

STD Claim Form (MT, ID, OR, WY)

STD Claim Form (WA)

LTD Claim Form (MT, ID, OR, WY)

LTD Claim Form (WA)

Death Claim Form (MT, ID, OR, WY)

Death Claim Form (WA)

Mountain Vision

Employer Agreement

Employee Agreement

TBG Flex

Employer FSA Plan Application

Employer POP Plan Application

Employer Deposit EFT (optional)

Employee Reimbursement EFT (optional)

United Heritage

Employer Group Life Application

Employer Group STD Application

Employer Group LTD Application

Employer Additional (Voluntary) Life Application

Employee Enrollment Form

Evidence of Insurability (MT, OR)

Evidence of Insurability (ID, WA, WY)

Final Expense Enrollment Form

Administration Card

Conversion Card

Unum

Employer Application

Employee Enrollment Form

Client Information Sheet

Broker Compensation

MiniPlan/Benefit Advantage Employer Application

MiniPlan/Benefit Advantage Employee Enrollment Form

MiniPlan/Benefit Advantage Client Information Sheet

Unum Life-Disability EOI Form

Beneficiary Card

Request for Change

Death Claim Form

Life Conversion

Life Portability

Usable Life

Please visit www.usablelife.com/Tools/FormFinder/MapPage.htm for form downloads

VSP

Employer Group Participation Application

Employer Group Setup Form

Employee Enrollment Form

NOTE
State specific forms are
identified with an abbreviation,
e.g., Employer Application (ID)

RFP for All Products
Download and Submit for Proposals