Please follow the detailed instructions on the claim form. To expedite your claim, it is important that you send us as much information as possible. Delays can be experienced when incomplete information is submitted. Depending on the claim submitted, the following information will be needed along with the completed claim form. Additional authorizations may be obtained from the claims department for further review of your claim.
There are 3 sections of the initial claim form. Part A, which is your section of the claim form, Part B, which is the employer's section of the claim form and Part C, which is the attending physician's section of the claim form. Please make sure to sign and date the authorization in Part A.
Disability Claim Form
Itemized bill showing admission and discharge dates, inpatient room charges (semi or private room charges), diagnosis and a signed and dated HIPPA authorization.
Hospitalization Claim Form
Complete description of your accident. If the accident was motor vehicle accident, a copy of the police or accident report is required. If your injury occurred on the job, a first report of injury filed with your employer will need to be attached to the completed claim form. If you were first treated in the emergency room, a copy of the discharge papers from the hospital will be required to verify the first date of treatment.
Accident Claim Form
Health Screening or Wellness Claims
Please fully complete the claim form for the Accident Wellness Benefit or the Critical Illness Screening Benefit. Copies of the doctor’s charge and/or bill is no longer required.
Accident Wellness Benefit Claim Form
Critical Illness Wellness Benefit Claim Form
Critical Illness Claims
Medical documentation required for specific critical illness (see claim form), birth certificate, names of all doctors and hospital in attendance and a signed and dated HIPPA authorization.
Critical Illness Claim Form
Pathology report used in the diagnosis of a malignant cancer, birth certificate, any itemized medical bills with the diagnosis and procedure codes and a signed and dated HIPPA authorization.
Cancer Claim Form
Please complete the Patient section, boxes 8-18, as well as the Policyholder/Employee section. (Excluding boxes 31-38 and 40.) Your dentist should complete the Billing Dentist section, Boxes 42- 66. (Excluding box 53)
Dental Claim Form
Beneficiary's Statement for Death Claim
A certified copy of the birth and death certificate. If the cause of death is due to and injury or accident, a copy of the police report is required. The beneficiary must sign and print their name at the bottom of the claim form.
Beneficiary's Statement for Death Claim Form