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Forms Center

For your convenience, you can download and print forms online. Instructions for completing and submitting your request are provided on each form.

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Forms Center
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For your convenience, you can download and print forms online. Instructions for completing and submitting your request are provided on each form.

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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.

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The information on this website is not a contract. Protective refers to Protective Life Insurance Company (PLICO) and its affiliates, including Protective Life and Annuity Company (PLAIC). PLICO, founded in 1907, is located in Nashville, TN and is licensed in all states excluding New York. PLAIC is located in Birmingham, AL, and is licensed in New York.

Protective® is a registered trademark of PLICO. The Protective trademarks, logos and service marks are property of PLICO and are protected by copyright, trademark, and/or other proprietary rights and laws. ADA® is a registered trademark of the American Dental Association (ADA). ADA Members Insurance Plans® is a registered service mark of the ADA. The ADA trademarks, logos, and service marks are the property of the ADA and used by Protective with permission. In some states, the ADA is entitled to receive royalties from the ADA Members Insurance Plans.

ADA Members Insurance Plans refers to the group life, disability, and supplemental medical policies issued by PLICO and PLAIC to the ADA.

Policies issued by PLICO in all states except New York: Term Life Insurance1 (TL-P 1-21), Student Term Life Insurance (TL-ST-P 2-21), Universal Life Insurance1 (TP-P 11-20), Level Term Insurance2 (LT-P 1-21), Disability Income Protection Insurance3 (IP-P 7-20), Office Overhead Expense Disability Insurance4 (OE-P 9-20), Student Disability Income Insurance3 (ST-P 8-20), Hospital Indemnity Insurance (HI-P 11-20), and Critical Illness Insurance (CI-P 7-20).

In New York, policies issued by PLAIC: Term Life Insurance1 (TL-P-NY 1-21), Student Term Life Insurance (TL-ST-P-NY 2-21), Universal Life Insurance1 (TP-P-NY 2-21), Level Term Life Insurance2 (LT-P-NY 2-21), Disability Income Protection Insurance3 (IP-P-NY 12-20), Office Overhead Expense Disability Insurance4 (OE-P-NY 01-21), Student Disability Income Insurance1 (ST-P-NY 1-21), Hospital Indemnity Insurance (HI-P-NY 1-21), and Critical Illness Insurance (CI-P-NY).

Consult the policy for benefits, riders, limitations, and exclusions. Benefits adjusted for misstatements of age or sex. Benefits are provided under a group policy issued to the ADA. Each Plan participant will receive a Certificate of Insurance explaining the terms and conditions of the policy. An insured must maintain continuous ADA membership to remain eligible for insurance.

1For term life insurance and universal life insurance, premiums increase annually based on age. The Premium Credit is not guaranteed but reevaluated periodically. Universal life recommended premiums consist of the costs of insurance (which vary based on the member’s age and coverage amount), the amount a member places into the Policy Value Account and service charge. Premium deposits may fluctuate or remain level.

2For level term life insurance, premiums are fixed based on the member’s age, gender and coverage amount at issue.

3Premiums increase every five years based on age for disability income protection. Premium Credit is not guaranteed but reevaluated periodically.

4Premiums increase every 10 years based on age to age 60 and every 5 years thereafter to age 75 for office overhead expense disability. Premium credit is not guaranteed but reevaluated periodically.

Coverage for dental student members is issued regardless of condition if under age 60. Coverage automatically renews each academic year. Individuals may convert coverage to the plans for practicing dentists after graduation by paying member premiums and maintaining continuous ADA membership.

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