Frequently Used Forms
Specialty Claim Forms
- Accidental Dental Claim Form
- Ambulance/Medical Transfer Claim Form
- Assisted Care Nursing Recommendation Claim Form
- Glucose Monitoring Special Authorization Request Form
- Hospital Claim Form
- Orthotics, Orthopedic Shoes and Modifications Claim Form
- Pre-Authorization Request Form
- Direct Deposit Application Form
- Provider Direct Deposit (for Providers only)
- Pre-Authorized Debit Form (for Individuals)
For Emergency Health Claims, submit the:
For Trip Cancellation Claims, submit the:
For Baggage Claims, submit the:
Disability Benefit Forms
Three forms are required for an application: an Employee's Statement, Employer's Statement (including a Job Analysis or a detailed job description), and an Attending Physician's Statement.
Group Life Forms
For life benefit proceeds of $250,000 or greater, a Proof of Death Physician's Statement must be submitted with the Group Life Benefit Claim Form.
Critical Illness Forms
Both of the following forms must be submitted when applying for the Critical Condition Benefit.