Claims & Insurance Forms

(NOTE: This is NOT a Change of Beneficiary Form)

File a claim for dental services.

In order to file a claim, complete, date, sign and return this form with one of the following: 1) A UB-04 form issued by the hospital. 2) An itemized hospital bill, along with a diagnosis provided by your attending physician. A balance due statement is not acceptable. 3) A statement from the hospital indicated the admission date, discharge date, number of days, type of room and diagnosis.

File a claim for Catastrophic Major Medical insurance.

Please contact Customer Care at 800.458.5736 (8 am – 5 pm CT, Monday – Friday).

Add dependent(s) to your coverage.

Add another address/individual to your account. They will receive a copy of billing and lapse notices to help prevent unintentional lapse of insurance coverage.