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On the next page you'll be asked to provide the amount you wish to pay as well as select the Plan to which your payment should apply. If you wish to pay premiums for multiple plans, you'll need to repeat the process for each plan.
For your convenience, you can download and print forms online. Instructions for completing and submitting your request are provided on each form.
Please download the forms for the state you are a resident in and print and return by email, fax or mail. If you have any questions concerning new or increased coverage or wish to have the application mailed to you please contact a Plan Specialist at ADAPlanSpecialist@protective.com or 866.607.5338.
Select the state you live in for the Life Insurance application forms available in that state. Then simply select the form to download as a PDF.
Select the state you live in for the Disability Insurance application forms available in that state. Then simply select the form to download as a PDF.
Select the state you live in for the Supplemental Medical Insurance application forms available in that state. Then simply select the form to download as a PDF.
Select the state you live in for the Dental Student Insurance application forms available in that state. Then simply select the form to download as a PDF.
Select the State you live in for the Initial Claim forms available in that State. Then simply select the form to download as a PDF.
Questions? Talk with an Insurance Plan Specialist at 866-607-5338 for assistance (weekdays from 8 a.m. to 6 p.m. Central Time) or Email ADAPlanSpecialist@protective.com.
Please contact a Plan Specialist at ADAPlanSpecialist@protective.com or 866.607.5338 to request your specific state application.