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)