Medical/Dental Claim Form

  • Part I - EMPLOYEE INFORMATION

  • Part II - COMPLETE ONLY IF CLAIM IS FOR DEPENDENT

  • Part III - OTHER INSURANCE INFORMATION

  • Part IV - ILLNESS/ACCIDENT DATA

  • Give a brief desciption of the accident/injury/illness above.
  • Part V - AUTHORIZATION OF PAYMENT

  • Please upload any necessary supporting documentation such as statements, bills, receipts, etc.