Jun 25, 2017

Applications & Forms

The following insurance plans are available to active members of AIChE. Please visit the insurance product pages on this website to review the full eligibility requirements of each plan.

Life Insurance Plans

Group Term Life Insurance – Coverage amounts from $10,000 ($20,000 in Oregon) to $1,000,000

Apply Online (available to members under age 60)
Download PDF (available to members under age 70)

Group 10-Year Level Term Life Insurance – Coverage amounts from $100,000 to $2,000,000

Apply Online (available to members under age 65)
Download PDF (available to members under age 65)

Group 20-Year Level Term Life Insurance – Coverage amounts from $100,000 to $2,000,000

Apply Online (available to members under age 55)
Download PDF (available to members under age 55) 

Group Disability Income Insurance

Download PDF
Coverage not available for residents of NH and VT.
 

Group Accidental Death & Dismemberment (AD&D) Insurance

Download PDF (available to members under age 70)
Coverage not available for residents of FL, VT and WA.
 

Supplemental Forms

Declaration of Domestic Partnership Form – Complete this form and return it with your application if you are applying for coverage for a domestic partner (not required for residents of OR). Domestic Partnerships and Civil Unions are determined by state law.

Beneficiary Designation Change Form – Complete this form if you would like to change beneficiaries on your existing plan.

Group Dental Program

Download PDF

Cancer Expense Insurance

Download PDF – KS residents
Download PDF – WI residents
Download PDF – WI guide to health insurance
Download PDF – residents of all other states
Coverage is currently not available for residents of CT, GA, ID, LA, MA, ME, MN, NH, NJ, NY, OR, SD, TN, UT, VT, WA, WI, WY.