GAP Forms

Claims, Cancellation, Declination and Contract Reporting

If you need to file a GAP claim or cancel coverage, please use the form that corresponds to the carrier specified on the original member contract (waiver). File the claim form with the original carrier, following the instructions provided on the form. 

Claim Forms	Form Description
Claim Form	CUMIS Insurance Society (CUNA Mutual Group)  This is a fillable form. Use the tab key to navigate from field to field.
Claim Form for New York	CUMIS Insurance Society (CUNA Mutual Group)  This is a fillable form. Use the tab key to navigate from field to field.
Claim Form	Philadelphia Insurance Company
Claim Form	OwnerGuard Corp.
Cancellation Forms	Form Description
Cancellation Form	Philadelphia Insurance Company and CUMIS - This is a fillable form. Use the tab key to navigate from field to field.
Cancellation Form	OwnerGUARD Corp.
Other Forms	Form Description
GAP Declination Form	Use this form to document that the member was provided with the opportunity to purchase coverage, but it was declined.
Contract Reporting Form-CUMIS	This form is used if your credit union is submitting paper member contracts (waivers) to CUNA Mutual Group.  Use this form to record and submit the contracts with payment to CUMIS. This form should be completed, and payment remitted within 30 days of issuing GAP contracts or within 15 days after the current month.
Contact Information:
If you have any questions or problems with any of the forms listed above, please contact your CUNA Mutual Sales Executive at 800-356-2644.