Claim Forms
Adobe Reader required to view forms. If you do not have Adobe Reader, click here for a free download.
Dental Claim Form
If your plan includes dental coverage, this form is to be completed by the employee or provider for payment of claims. Attach itemized statements, including date, type and place of service, fees, and signature of provider or representative.
Short-Term Disability (Proof of Loss Form)
Medical/Rx Claim Form (English)
Medical/Rx Claim Form (Spanish)
Missed Premium Direct Payment Form
Missed Premium Direct Payment Form (Spanish)
Term Life or Accidental Death & Dismemberment (AD&D) Claim Form