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 TEXAS ONLY Funeral Homes - Claim Form and other 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
Change Billing Address	Request for Policy Loan
Correct Insured's Age	Request for Certificate
Change Premium Mode	Request Extended Term Option
Change Beneficiary	Request Reduced Paid-Up Option
Change Name	Cash Surrender
Change Ownership	Request to Cancel Policy (no cash value)
W-9 Certified (Taxpayer Identification Number Request)

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	Maryland
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)	Group Insurance Enrollment Form Group Insurance Request for Change Form
Underwriting
Nicotine Usage Questionnaire (Florida only)	Nicotine Usage 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)