Download Form #67715
Submit an accident claim. If you are also filing for disability benefits, please complete the Disability claim form.
Download Form #57930
Submit a claim for the catastrophic accident benefit.
Download Form #46988
Submit additional information for your on-going disability claim.
Download Form #65017
Submit a claim for the critical illness benefit.
Download a dental policy claim form to submit to HealthPlan Service.
Download Form #64387
Submit a disability claim.
Download Form #69121
Doctor's Office Visit
Submit a claim form if your policy has a doctor’s office visit, telemedicine, or prescription drug benefit.
Download Form #70067
Health/Wellness/Well Being Claim (older than 3 years)
Express filing of health, wellness or well being claims that are older than 3 years.
Download Form #57644
HIPAA Authorization Form
Should be completed and returned with each claim form submitted.
Download Form #100713
Hospital Confinement/Outpatient Surgery
Submit a Hospital Confinement/Outpatient Surgery claim.
Download Form #49507
Express filing of pregnancy claims once you deliver. If you are filing for complications prior to delivery, please complete the Universal Claim Form.
Download Form #08727
Universal Claim Form
Submit a claim for disability, cancer, accident, and hospital confinement.