Providers

Forms

I want to...

Complete new business documents for:

     Agent Checklist for Prescreens and Sold Groups
 

Change my group’s coverage
 

Drop or add a member to my group’s coverage:

  • Enrollment Form

     
  • Waiver Form - Michigan

     
  • Waiver Form - IL, IN, OH, WI
  • Complete a Billing Adjustment Worksheet

Make a death claim

  • Employer must complete a Death Claim Form

Make a disability claim

  • Employer, employee and attending physician must complete a Disability Claim Form

Designate an authorized user of the employer secure services portal

  • Group’s authorized representative must complete an Employer Portal Authorized Access Form

Authorize an individual to obtain my personal health information (PHI)

  • Member must complete a Designation of Person to Obtain PHI Form

 

Get appointed with USHL

Register for USHL online agent quoting