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.
descriptionAccident Insurance Claim FormdescriptionAdd Household Discount to Medicare Supplementaccount_circleAddress ChangedescriptionAddress ChangedescriptionAge Correctionaccount_circleAutomatic Bank WithdrawaldescriptionAutomatic Bank WithdrawaldescriptionBeneficiary FormdescriptionBilling Statement ReplacementdescriptionDental Claim Appeal/Grievance FormdescriptionDental Insurance Claim FormdescriptionDuplicate Copy of Insurance PolicydescriptionHIPAA AuthorizationdescriptionHospitalization/Cancer Insurance Claim FormdescriptionID Card ReplacementdescriptionLife Insurance Claim FormdescriptionLife Ownership Change RequestdescriptionLong-Term Care Assignment BenefitsdescriptionSubmit Long Term Care ClaimdescriptionLong-Term Patient Care Flow SheetdescriptionLong-Term Plan of Care TreatmentdescriptionMedicare Supplement Insurance Claim FormdescriptionMedicare Supplement Discount Form for New DentaldescriptionName ChangedescriptionNext of KindescriptionPet Insurance Cancellationaccount_circleRequest a Billaccount_circleRequest a Duplicate Copy of Insurance Policyaccount_circleRequest a Replacement Health ID Card