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Claim Forms for Download

Certain Employers/Plan Sponsors may have customized forms, designed by/for their plan.  Please see your Human Resources Deparment for these forms if other than those listed below. 

Please submit claims to the address on the back of your Member ID Card.

Forms available for download:

Adobe Acrobat Document, 983kb

Medical Claim Form

Adobe Acrobat Document, 983kbDental Claim Form
Adobe Acrobat Document, 983kbVision Claim Form
Adobe Acrobat Document, 983kb

Flex Claim Form

Adobe Acrobat Document, 983kbDisability Claim Form
Adobe Acrobat Document, 983kbPrescription Claim Form


You must have the free Adobe Acrobat® Reader software installed on your computer to read these files. You can download Adobe Acrobat® Reader at Adobe's Website by selecting the version appropriate for your type of computer.