Department


Investors Heritage Life Insurance Company 200 Capital Avenue - PO Box 717 Frankfort - Kentucky - 40602-0717 Phone : 502-223-2361 Toll Free : 800-422-2011 Fax : 502-875-7084 E-Mail: IHLIC@ihlic.com
All forms are in .pdf format. They may be viewed using Adobe Acrobat Reader. If you do not have the software, Acrobat Reader is available for free download. Click the Acrobat Reader logo to connect to the Adobe website.
Please type in requested information, print form, have the necessary individuals sign the form. These forms require signatures and therefore must be mailed to Investors Heritage at the address above.
Agency Request for Electronic Commission Banking Supply Request Form
Preneed Assigned Benefit Payments Funeral Homes - Claim Forms for Assigned Policies
Ordinary Individual Benefit Payments Claimants - Claim Forms
Credit Life Accounting Report & Remittance Form
Credit Life and Disability Benefit Payments Initial Claim Forms for Credit Disability (Use these forms for the first initial filing of a claim. All forms must be fully completed, signed and dated.) Continuation Claim Forms for Credit Disability (Use these forms each month to continue filing for a disability claim. All forms must be fully completed, signed and dated.) Death Claim Statement (Contains both the Creditor Death Claim Statement and Claimant Statement. All forms must be fully completed, signed and dated.) Authorization for Medical Records (HIPAA Compliant) (All states except Virginia)
Virginia Individual Authorization for Medical Records (HIPAA Compliant) - Claims Only

Policyowner Service
Request for Change (Form 75)		Request for Policy Loan
Change Billing Address		Release Assignment
Cash Surrender		Request Extended Term Option
Correct Insured's Age		Change Beneficiary
Change Premium Mode		Change Name
Request Reduced Paid-Up Option		Change Ownership
Request for Certificate		Request to Cancel Policy (no cash value)
W-9 Certified (Taxpayer Identification Number Request)
W-4P-2007 Withholding Certificate for Pensions or Annuities

Reinstatement Forms: Reinstatements are based on the state in which the original application was applied and signed, not the current state of residence. Please note: All reinstatement forms must be printed on Legal paper. Click state where application was applied and signed for correct form.
Alabama	Arizona	Arkansas
Colorado	Florida	Georgia
Illinois	Indiana	Kansas
Kentucky	Louisiana
Michigan	Mississippi	Missouri
Montana	Nebraska	New Mexico
North Carolina	North Dakota	Ohio
Oklahoma	Pennsylvania	South Carolina
South Dakota	Tennessee	Texas
Utah	Virginia	West Virginia

Premium Accounting
Request Preauthorized Transfer (PAT)

Underwriting
Cigarette Smoking Questionnaire (KY/OH only)		Cigarette Smoking Questionnaire (all other states)
Parent Consent Form		Individual Authorization for Medical Records (HIPAA Compliant) except Virginia
Illustration NOT Provided at Application		Joint Authorization for Medical Records (HIPAA Compliant) except Virginia
Good Health Statement		Virginia Individual Authorization for Medical Records (HIPAA Compliant)
		Virginia Joint Authorization for Medical Records (HIPAA Compliant)