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HIPAA Privacy Notice

Change & Request Forms

Change Form MP-2
Use form MP-2 to perform any of the following policy modifications or requests:
  > Change Address
  > Change Beneficiaries
  > Change Name
  > Change Policy Ownership
  > Change Occupation
  > Remove Dependent Coverage
  > Remove Rider from Coverage
  > Request for Duplicate Policy

Form MP-3
Use form MP-3 to apply for reinstatement of insurance coverage.
(Note: does not include cancer coverage, see form MP-4)

Form MP-4
Use form MP-4 to apply for reinstatement of cancer insurance coverage.

Form APLCOB-APP
Use form APLCOB-APP to apply for continuation of health coverage (COBRA).

Form G-112R
Use form G-112R to authorize American Public Life to honor checks or electronic transfer of funds.

Form PRDAuth
Use form PRDAuth to add, change or cancel your payroll deductions.

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