Policyholders

Choose one of the claim form options below to print out the appropriate claim form for your state:

• Health and Disability Benefit Forms
  
  
• Wellness Benefit Claim Forms
  
  
• Death Benefit Claim Forms
  

Once you have completed the claim form as noted in the Instructions or Instructions for Filing Proof of Loss provided on the claim form, you should mail the form, along with any appropriate attachments, to the address shown on the top of the form. We will also accept a faxed copy of the form to begin processing your claim. However, it is necessary that you mail the form with your original signature and attachments to us as well.

In order to allow us to obtain medical records to process your claim, you must complete the Authorization for Release of Health-Related Information Form that is attached to the claim form.

Submit the Authorization for Release of Health-Related Information Form with the Claimant's Statement to comply with federal and state privacy regulations. Failure to include the completed form with the Claimant's Statement may delay the processing of your claim request.