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Forms

Online forms — access online forms by logging into My Account, then fill out the brief online form and you're done. You'll be notified by email when we receive your request. Printable forms — print your form, complete the appropriate sections, and then mail it to us. To open and view the printable forms, you will need Adobe Reader .

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Accident Insurance Claim FormAdd Household Discount to Medicare Supplement Address Change Address Change Age Correction Automatic Bank Withdrawal Automatic Bank Withdrawal Beneficiary Form Billing Statement Replacement Collateral Assignment Form Dental Claim Appeal / Grievance Form Dental Insurance Claim Form Dental NY Designate a Representative Duplicate Copy of Insurance Policy HIPAA Authorization Hospitalization / Cancer Insurance Claim Form ID Card Replacement Life Insurance Claim Form Life Ownership Change Request Long-Term Care Assignment Benefits Submit Long Term Care ClaimLong-Term Patient Care Flow Sheet Long-Term Plan of Care Treatment Medicare Supplement Insurance Claim Form Medicare Supplement Discount Form for New Dental Monthly Facility Verification Form Name Change Next of Kin Pet Insurance Cancellation Request a Bill Request a Duplicate Copy of Insurance Policy Request a Replacement Health ID Card