Cobra Administration Form
(PDF - 172 KB)
This form is used to determine any other coverages for a participant who has elected Cobra.
Debit Card Pin Number
(PDF - 177 KB)
Instructions for obtaining a Debit Card Pin Number
Dental Claim Form
(PDF - 166.6 KB)
This form is used to submit dental claims
Designation of Personal Representative
(PDF - 152.1 KB)
This form should be used when a covered employee or dependent wishes to designate an authorized personal representative to have access to their claim information and other personal health data.
Disability Claim Form
(PDF - 350 KB)
This from is used to submit a disability claim
(PDF - 65.6 KB)
Explanation of Benefits
Flexible Spending Account Claim Form
(PDF - 814.9 KB)
FSA Claim form
Health Reimbursement Arrangement Claim Form (HRA)
(PDF - 62.5 KB)
This form should be used when a covered employee or dependent wishes to request reimbursement from their HRA
Medical Claim Form
(PDF - 105.1 KB)
This form is used to verify employee eligibility for group health plan coverage. This form may also be used to submit a group health plan claim, however claim forms are not required.
Request for Duplicate Coverage
(PDF - 93.6 KB)
This form is required at least once per year to verify if dependents have other coverage.
(PDF - 256.9 KB)
SBC Uniform Glossary
(PDF - 91.7 KB)
The Glossary of terms for the SBC
Section 125 213d eligible expenses
(PDF - 129.1 KB)
Summary of eligible expenses under 213d
Supplemental Accident Questionnaire
(PDF - 168.5 KB)
This form is required for claims related to an accident. Please complete and return to Significa Benefit Services.
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