Illinois Life and Health Insurance Guaranty Association

Life & Health Insurance Company of America (LHICA)

Please select a form below for Life & Health Insurance Company of America (LHICA).

• ACH (Automatic Draft) Authorization Form
• Address Change Form
• Assignment of Benefits Form
• Assisted Living/Nursing Home Claim Packet
• Authorization to Release Information Form
• Cancellation Request Form
• Estate Affidavit Form
• Home Health Care Claim Packet
• Monthly Care Certification Form
• Physician Statement (Home Health Care)
• Physician Statement (Long Term Care)
• Weekly Care Certification Form

Please note that these forms are “fillable,” so you may type the information requested directly into the form. If you are looking for information that has not been provided on our website, please contact us using one of the methods available below, so we may accommodate your concerns.

Illinois Life & Health Insurance Guaranty Association
Email: ILClaims@illinoisga.org
Phone: 773.444.4071
Fax: 773.304.3559
Mail: P.O Box 4198
Lisle, IL 60532

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