Forms

Forms with this icon mouse icon can be submitted directly to us via this web site.

Forms with this iconpdf are in PDF format. You will need Adobe Reader to view and print the documents. These documents will need to be faxed to us at 515-247-2435 or sent to us via mail.

Billing

Change Billing Information mouse icon
Use this form to change your billing address.

American Republic Insurance Company Automatic Premium Payment Change pdf
Use this form to change your bank or method of premium payment for automatic monthly withdrawals.

American Republic Corp Insurance Company Automatic Premium Payment Change pdf
Use this form to change your bank or method of premium payment for automatic monthly withdrawals.

Policy

Order Duplicate Identification Card mouse icon
Use this form to request a duplicate ID card.

Change Policyholder Personal Information mouse icon
Use this form to update your address.

Request Coverage Information mouse icon
Use this form to request information regarding your policy.

Maryland Mandated Benefit Notice  
If you are a Maryland policyholder with major medical coverage, please read this notice about benefits for treatment of mental illnesses, emotional disorders, and drug and alcohol abuse that have been enacted by the state of Maryland.

Maryland Notice of Access to Information about Proposed Rate Increases mouse icon 
Maryland insureds may access information about proposed rate increases and submit comments regarding proposed rate increases on the Maryland Insurance Administration's website at www.mdinsurance.state.md.us.

Oregon Policyholder Estimate of Costs 
If you are an Oregon policyholder with major medical coverage, please read this notice for detailed instructions to obtain an estimate of costs.

Affidavit to Authorize American Republic Insurance Company to Pay Policy Benefitspdf
Use this form to have a check reissued that was previously issued to the estate.

Affidavit to Authorize American Republic Corp Insurance Company to Pay Policy Benefitspdf 
(Medicare Supplement Insurance)
Use this form to have a check reissued that was previously issued to the estate.

Privacy Authorization Form - American Republic Insurance Companypdf
Use this document to grant covered entity permission to release information to designated individuals.

Privacy Authorization Form - American Republic Corp Insurance Company (Medicare Supplement Insurance)pdf
Use this document to grant covered entity permission to release information to designated individuals.

Nebraska External Review Request Form  
This form is only applicable for Nebraska insureds.

Claims

Long-term care Claims

Long Term Care Claim Formpdf
Use this form to submit a claim regarding Long Term Care policies.

CareAssist Claims

American Republic Insurance Company CareAssist Claim Formpdf
Use this form to submit a claim regarding American Republic Insurance Company CareAssist polices.

American Republic Corp Insurance Company CareAssist Claim Formpdf
Use this form to submit a claim regarding American Republic Corp Insurance Company CareAssist polices.

UltraComp Critical IllnessPlus and UltraComp Cancer CarePlus Claims

Use these claim forms when filing a critical illness/cancer claim with UltraComp policies.

Policyholder Claim Form – To be completed by the insured or authorized person

Provider Claim Form – First Coronary Artery Bypass Surgery

Provider Claim Form – Myocardial Infarction (Heart Attack)

Provider Claim Form – Multiple Sclerosis

Provider Claim Form – Paralysis

Provider Claim Form – End Stage Renal Disease

Provider Claim Form – Cerebro-Vascular Accident or “Stroke”

Provider Claim Form – Condition Requiring Transplantation

Provider Claim Form – Diagnosis of Cancer 

Pharmacy

Prescription Drug Claim Form pdf
Need to make a claim for a prescription drug? This is the form you need to submit to ExpressScripts, Inc.

General

Ask for Company Information mouse icon
Have general questions regarding our company?

Submit a Question mouse icon
Have a question or want to give us feedback?

Life Insurance

Life Policy Beneficiary Change pdf
Make changes to the beneficiary designation on your life insurance policy.

Life Policy Absolute Assignment pdf
Change the ownership on a life insurance policy.

Privacy Authorization Form - American Republic Insurance Company (Life Insurance)
Use this document to grant covered entity permission to release information to designated individuals.

Cash Surrender Value Request pdf
Cancel your life insurance policy with cash value and receive the cash surrender value.

Partial Cash Surrender Value Request pdf
Take a partial withdrawal from the cash value of your LifeSavings policy but maintain coverage with decreased death benefit.

Policy Loan Agreement pdf
Use this form to borrow from the cash value on a policy.

Extended Term Insurance Request pdf
Request to use cash value to extend length policy without paying any further premium payments.

Dividend Options pdf
If dividends are earned, this form will change the way dividends are paid. Use this form to update name or address.

Reduced Paid-Up Insurance Request pdf
To use the cash value to reduce death benefit without any further premium payment.

Proof of Death pdf
This form is required when filing a Death Claim for a Life Insurance Policy. Used in conjunction with the W-9 form.

W-9 Form pdf
This form is required when filing a Death Claim for a Life Insurance Policy. Used in conjunction with the Proof of Death form.

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Please Select Your State

American Republic Insurance Company serves customers in many states. However, not all products are available in all states.

Please select your state to continue.

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Not connected with or endorsed by the United States government or the Federal Medicare program.

Please Select Your State

American Republic Insurance Company serves customers in many states. However, not all products are available in all states.

Please select your state to continue.

 Go   Close


Not connected with or endorsed by the United States government or the Federal Medicare program.

Please Select Your State

American Republic Corp Insurance Company serves customers in many states. However, not all products are available in all states.

Please select your state to continue.

Go   Close

Not connected with or endorsed by the United States government or the Federal Medicare program.