Policy Service Forms

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1. Download and Print Form
2. Complete Form
3. Fax or Mail the completed form using the information below.

Beneficiary Change Form

• Beneficiary changes are made by completing the Beneficiary Change Request Form  
• Returning Fax: 615-749-2941
• Mailing Address: Customer Service; PO BOX 305355 MC338N; Nashville TN 37230-5355

Address/Name Change Form

• Address/Name Changes changes are made by completing the Name/Address Change Request Form  
• Returning Fax: 615-749-2941
• Mailing Address: Customer Service; PO BOX 305355 MC338N; Nashville TN 37230-5355

Automatic Bank Draft Request/Change Form

• Your payment will be withdrawn from your designated savings or checking account, based on the mode and withdrawal day you selected. Automatic Bank Draft also known as ABC, is a safe and convenient method of paying your premiums from your checking or savings account. 
• On many policies, premiums are less using this payment method.  Deductions can be made monthly, quarterly, semi-annually, or annually on the day you choose.  You never have to write another check or worry about a late payment. 
• Complete the ABC Authorization Form
• Returning Fax: 615-749-2224,
• Mailing Address: Customer Service; PO BOX 305355 MC338N; Nashville TN 37230-5355
• E-mail: ABC.Inquiries@agla.com

Lost Policy Application Form

• A policy copy may be requested by completing the Lost Policy Application Form  
• Returning Fax: 615-749-2941
• Mailing Address: Customer Service; PO BOX 305355 MC338N; Nashville TN 37230-5355
• E-mail: CS.Traditional.Policy.Changes@agla.com

Policy Loan Application      

• If the policy has loan value you can apply for a loan by completing the Policy Loan Application Form
• Returning Fax: 615-749-2941
• Mailing Address: Customer Service; PO BOX 305355 MC338N; Nashville TN 37230-5355
• E-mail: AGLA.Complex.Support@agla.com

Absolute Assignment Form

• A policy can be assigned by completing the Absolute Assignment AGLA5051
• Returning Fax: 615-749-2941
• Mailing Address: Customer Service; PO BOX 305355 MC338N; Nashville TN 37230-5355
• E-Mail: AGLA.Complex.Support@agla.com

HIPAA Authorization Forms

• HIPAA Authorization Health Customer Service Policy Change
• Returning Fax: 615-749-2941
• Mailing Address: Customer Service; PO BOX 305355 MC338N; Nashville TN 37230-5355
• E-mail: CS.Traditional.Policy.Changes@agla.com

• HIPAA Authorization Life Customer Service Policy Change
• Returning Fax: 615-749-2941
• Mailing Address: Customer Service; PO BOX 305355 MC338N; Nashville TN 37230-5355
• E-mail: CS.Traditional.Policy.Changes@agla.com

Claim Forms

Please visit our Policy Claims Forms section.

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