State Applications

Please visit the Getting Started page and select your state application using Step 1.
If you prefer to print and mail an application, click here.

online applications

Online Claim Submission

submit a claim

check claim status

If you prefer to print and mail a claim, please choose your carrier below. Note: Turnaround time for claims submitted electronically is significantly faster. 
Pan-American Life printable claim form
Unified Life printable claim form

Update Eligibility (Change Form)

Click here to update contact information, add or term dependents, or make other eligibility changes.

update eligibility

Privacy Rule Authorization

This form is the participant's signed permission to allow a covered entity to discuss or disclose the participant's protected health information (PHI).

privacy authorization

Agent Information

Unified Life - Producer Application

Pan-American Life - Producer Application

Pan-American Life Insurance Group - "How We Do Business" brochure

Electronic Funds Transfer (EFT) Form

This form is the participant's signed permission to allow BeniComp to reimburse claims directly into their bank account electronically.

eft form