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Untitled Document

CLAIM FORMS

Health

 

*  Medical Benefits Claim Form

(English)

(Spanish)

 

Dental

 

*  ALIC Attending Dentist Statement

 

*  MDP Attending Dentist Statement

 

Vision

 

*  Vision Care Benefit Claim Form

 

 

W.I.

(Disability)

Short Term Disability (WI) Claim Form (3 Pages)

 

 

* Employee Statement (Page 1)

 

*  Employer Statement (Page 2)

*  Physician Statement (Page 3)

 

Life

Death & Accidental Death Claim Form (4 Pages)

 

 

*  Employer Statement (Page 3)

 

*  Beneficiary Statement (Page 4)

Accidental Dismemberment Claim Form (3 Pages)

 

 

*  Employee Statement (Page 1)

 

*  Employer Statement (Page 2)

*  Physician Statement (Page 3)

Waiver of Premium Form (4 Pages)

 

*  Employee Statement (Page 1-2)

 

*  Employer Statement (Page 3)

*  Physician Statement (Page 4)

 

Get Acrobat Reader

All forms are available in Adobe acrobat PDF format

 

 

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