BERKSHIRE DISABILITY FORMS
Agency Checklist for Completeness of Applications - AA1213-11-2003
Agents Certification - DI-AC-2003
Alcohol and Drug Useage Supplement - C-ADU-SUPP-2003
Alcohol and Drug Useage Supplement - C-ADU-SUPP-2007 [CA]
Application for Change-Reinstatement - Disability - 17CC-H (03-06) [CA]
Application for Change-Reinstatement - Disability Package [CA]
Application for Change-Reinstatement - Disability Package [IL]
Application for Change-Reinstatement - Health - 17CC-H (03-06)
Application for Change-Reinstatement - Health Package [MA]
Application for Change-Reinstatement - Health Package [TX]
Application for DI Option Exercises - Disability Buy-Out Insurance Supplement - FIO-DBO-2007
Application for DI Option Exercises - Disability Buy-Out Insurance Supplement - FIO-DBO-2007 [CA]
Application for DI Option Exercises - Disability Buy-Out Insurance Supplement - FIO-DBO-2007 [TX]
Application for DI Option Exercises - Individual DI Supplement - FIO-IDI-2007
Application for DI Option Exercises - Individual DI Supplement - FIO-IDI-2007 [CA]
Application for DI Option Exercises - Individual DI Supplement - FIO-IDI-2007 [TX]
Application for DI Option Exercises - Overhead Expense Insurance Supplement - FIO-OE-2007
Application for DI Option Exercises - Overhead Expense Insurance Supplement - FIO-OE-2007 [CA]
Application for DI Option Exercises - Overhead Expense Insurance Supplement - FIO-OE-2007 [TX]
Application for DI Option Exercises - Retirement Protection Plus IDI Supplement - FIO-RPP-2007
Application for DI Option Exercises - Retirement Protection Plus IDI Supplement - FIO-RPP-2007 [CA]
Application for DI Option Exercises - Retirement Protection Plus IDI Supplement - FIO-RPP-2007 [TX]
Application for Disability Insurance - 2007 Package [CA]
Application for Disability Insurance - 2007 Package [IL]
Application for Disability Insurance - 2007 Package [MA]
Application for Disability Insurance - 2007 Package [TX]
Application for Disability Insurance - 2007 Special Package [TX]
Application for Disability Insurance - Exercise of Future Option - 2001 Package [MA]
Application for Disability Insurance - Exercise of Future Option - 2001 Package [TX]
Application for Disability Insurance - Exercise of Future Option - 2007 Package [MA]
Application for Disability Insurance - Exercise of Future Option - 2007 Package [TX]
Application for Disability Insurance Option Exercises - FIO-2007
Application for Disability Insurance Option Exercises - FIO-2007 [CA]
Application for Disability Insurance Option Exercises - FIO-2007 [TX]
Application for Disability Insurance Option Exercises Package [CA]
Application for Disability Insurance Option Exercises Package [IL]
Application for Disability Insurance-Reinstatement - Package [CA]
Application for Exercise of FPO-FIO-GDR Option - 71-EXER (06-01)
Application for Exercise of FPO-FIO-GDR Option - 71-EXER (06-01) [MA]
Application for Exercise of FPO-FIO-GDR Option Package [CA]
Application for Exercise of FPO-FIO-GDR Option Package [IL]
Application for Exercise of FPO-FIO-GDR Option Package [MA]
Application for Exercise of FPO-FIO-GDR Option Package [TX]
Application for Health Policy Reinstatement - 17HR-2 (03-06)
Application for Health Policy Reinstatement - 17HR-2 (03-06) [CA]
Application for Health Policy Reinstatement Package [IL]
Application for Health Policy Reinstatement Package [MA]
Application for Health Policy Reinstatement Package [TX]
Application for Insurance - Part 1 - DI-2007
Application for Insurance - Part 1 - DI-2007 [CA]
Application for Insurance - Part 1 - DI-2007 [TX]
Application for Insurance - Part 1 Package [CA]
Application for Insurance - Part 1 Package [IL]
Application for Insurance - Part 1 Package [MA]
Application for Insurance - Part 1 Package [TX]
Application for Insurance - Part 2 Non-Medical - DI-NM-2007
Application for Insurance - Part 2 Non-Medical - DI-NM-2007 [CA]
Application for Insurance - Part 2 Non-Medical - DI-NM-2007 [TX]
Association Membership Confirmation Form - AA1706-3-2008
Authorization for Disclosure of Protected Health Information - AA1542-3-2006
Authorization to Obtain and Release Information - C-AUTH-2003
Authorization to Obtain and Release Information - C-AUTH-2003-1 [CA]
Authorization to Release Information - AA1093-3-2005
Authorization to Release Tax Information - AA288-8-2005
Automatic Increase Rider-Automatic Benefit Enhancer - AA955-1-2005
Automatic Increase Rider-Automatic Benefit Enhancer - AA955-1-2005 [CA]
Automatic Increase Rider-Automatic Benefit Enhancer Package [CA]
Automatic Increase Rider-Automatic Benefit Enhancer Package [IL]
Automatic Increase Rider-Automatic Benefit Enhancer Package [MA]
Automatic Increase Rider-Automatic Benefit Enhancer Package [TX]
Aviation Supplement - C-AVIA-SUPP-2003
Aviation Supplement - C-AVIA-SUPP-2007 [CA]
Avocations Supplement - C-AVOC-SUPP-2003
Avocations Supplement - C-AVOC-SUPP-2007 [CA]
Business Overhead Expense - DBO-R (05-05) [TX]
Business Overhead Expense Revision - BOE-R (05-05) [TX]
Business Overhead Expense Revision - BOE-R (06-01) [TX]
Catastrophic Disability Benefit Rider Supplement to Application - DI-CAT-SUPP-2006
Conditional Receipt (Required With All Prepayments) - 71-CR (06-01)
Conditional Receipt for Disability Insurance - DI-CR-2007
Conditions of Coverage - CC-2007
Dating Information - AA1153-9-2008 [CA]
Delivery Receipt - AA1154-9-2008 [CA]
DI TeleMed New Business - Transmittal - AA1489-3-2008
Disability Buy-Out Insurance Supplement to the Application for Insurance - DI-DBO-2007
Disability Buy-Out Insurance Supplement to the Application for Insurance - DI-DBO-2007 [CA]
Disability Buy-Out Insurance Supplement to the Application for Insurance - DI-DBO-2007 [TX]
Disability Insurance Application Instructions-Checklist - DI-AP-2007 [CA]
Disability Insurance Application Instructions-Checklist - DI-AP-2007 [IL]
Disability Insurance Application Instructions-Checklist - DI-APP-2007
Disability Insurance Application Instructions-Checklist - DI-APP-2007 [TX]
Executive II (Policy Form No 1600) - EXE (06-01) [TX]
Financial Supplement - 71-FS (06-01)
FIO-FPO-GDR Transmittal - AA1430 [TX]
FIO-FPO-GDR Transmittal - AA1430-1-2008
Guarantee Standard Issue - Guarantee to Issue And No Decline Request - AA979-3-2005
HIPAA Authorization to Obtain and Release Health-Related Information - HIPAA-AUTH-2003 [CA]
HIV-AIDS Consent Form - 3282-4-2007 [TX]
HIV-AIDS Consent Form - 3371-4-2007 [CA]
HIV-AIDS Consent Form - 3446-4-2007 [MA]
HIV-AIDS Consent Form - AA890-4-2007 [IL]
Income Provider (Policy Form No 1200) - IPOC-R (12-06) [TX]
Income Provider Disability Insurance Supplement to the Application for Insurance - DI-IPDI-2007
Income Provider Disability Insurance Supplement to the Application for Insurance - DI-IPDI-2007 [TX]
Individual Disability Insurance Supplement to the Application for Insurance - DI-TDI-2007
Individual Disability Insurance Supplement to the Application for Insurance - DI-TDI-2007 [CA]
Individual Disability Insurance Supplement to the Application for Insurance - DI-TDI-2007 [TX]
Instructions for Completing the Application for DI Option Exercises - FIO-AP-2007
Instructions for Completing the Application for DI Option Exercises - FIO-AP-2007 [CA]
Instructions for Completing the Application for DI Option Exercises - FIO-AP-2007 [TX]
Lab Results Letter [TX]
Military Income Eligibility - AA819-A-6-2005
New Business - Request to Reissue - AA1674-5-2008
New Business Transmittal - Disability - 2959-DI-1-2008
Notice of Insurance Information Practices - C-NIIP-2003
Notice of Insurance Information Practices - C-NIIP-2003 [CA]
Notice of Insurance Information Practices - C-NIIP-2003 [MA]
Overhead Expense Insurance Supplement to the Application for Insurance - DI-OE-2007
Overhead Expense Insurance Supplement to the Application for Insurance - DI-OE-2007 [CA]
Overhead Expense Insurance Supplement to the Application for Insurance - DI-OE-2007 [TX]
Policy Placement Instructions - 116-3-2005
Policy Receipt - AA107-3-2005
Producers Certification - DI-PC-2007
Producers Certification - FIO-PC-2007
Professional Overhead Expense - POE-R (06-01) [TX]
Provider Plus (Policy Form No 0100) - PPU (12-06) [TX]
Provider Plus (Policy Form No 1100) - PPD (12-06) [TX]
Provider Plus (Policy Form No 1400) - TDOC (03-07) [CA]
Provider Plus (Policy Form No 1400) - TDOC-R (03-07) [TX]
Provider Plus (Policy Form No 1500) - TUOC (03-07) [CA]
Provider Plus (Policy Form No 1500) - TUOC-R (03-07) [TX]
Reducing Term Insurance Supplement to the Application for Insurance - DI-RT-2007
Reducing Term Insurance Supplement to the Application for Insurance - DI-RT-2007 [CA]
Reducing Term Insurance Supplement to the Application for Insurance - DI-RT-2007 [TX]
Related Applications for Disability Income Insurance - AA1214-2-2005
Representations to the Medical Examiner - Berkshire Part 2 - C-MED-2007 [CA]
Representations to the Medical Examiner - Guardian Part 2 - M40-2000 [CA]
Representations to the Medical Examiner - Part 2 - C-MED-2003
Representations to the Medical Examiner - Part 2 - C-MED-2003 [TX]
Representations to the Medical Examiner - Part 2 Package (Berkshire DI Only) [CA]
Representations to the Medical Examiner - Part 2 Package (Guardian DI Only) [CA]
Representations to the Medical Examiner - Part 2 Package [IL]
Representations to the Medical Examiner - Part 2 Package [MA]
Representations to the Medical Examiner - Part 2 Package [TX]
Request for Case Approval - AA1127-1-2007
Request for Change - Disability Insurance - No Underwriting - AA1257 (10-04)
Request for Guard-O-Matic Arrangement - R223 (07-06)
Retirement Protection Plus Contribution Worksheet - AA1049-9-2005
Retirement Protection Plus Disability Benefit Rider Irrevocable Assignment - AA1335-2-2005
Retirement Protection Plus Program Authorization and Irrevocable Assignment - AA1032-9-2005
Retirement Protection Plus Program Individual Disability Insurance Supplement - DI-RPP-2007
Retirement Protection Plus Program Individual Disability Insurance Supplement - DI-RPP-2007 [CA]
Retirement Protection Plus Program Individual Disability Insurance Supplement - DI-RPP-2007 [TX]
Supplement to Application - AP-12-89 [CA]
Supplement to Application - C-AP-SUPP-2003
Supplement to Application - C-AP-SUPP-2007 [CA]
Suspense Ticket (Must be submitted with Prepayment and a Conditional Receipt) - 235-3-2005
TeleMed Request Form - AA1484-7-2008
Underwriting Inquiry - C-UNDINQ-2003
Underwriting Inquiry - C-UNDINQ-2007 [CA]
Underwriting Inquiry Package [CA]
Underwriting Inquiry Package [IL]
Voluntary Income Protection (VIP) Enrollment Form - AA1119-9-2002
Voluntary Income Protection Program Eligibility Confirmation - AA1670-7-2007
