Members
  

Member Forms

Cobra Administration Form (PDF - 46.5 KB)
This form is used to determine any other coverages for a participant who has elected Cobra.
Coordination of Benefits Form/Duplicate Coverage Inquiry Form (PDF - 46.1 KB)
This form is required at least once per year to verify if dependents have other coverage.
Dental Claim Form (PDF - 150.2 KB)
This form is used to submit a dental claim.
Designation of Personal Representative (PDF - 48.4 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 information.
Disability Claim Form (PDF - 78.6 KB)
This form is used to submit a disability claim.
EOB Sample (PDF - 65.6 KB)
Explanation of Benefits
Flexible Spending Account Claim Form (PDF - 38.9 KB)
This form is required to be submitted with all FSA claims. Be sure to include the Explanation of Benefit (EOB) from the plan (medical, dental, etc.).
Full-time Student Verification Form (PDF - 49 KB)
This form can be downloaded and sent to the student's college or university. It should be completed by the school to verify a student is full-time.
Health Plan Claim Form (PDF - 57.9 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.
Health Reimbursement Arrangement Claim Form (HRA) (PDF - 63.9 KB)
This form should be used when a covered employee or dependent wishes to request reimbursement from their HRA.
Medical Expense Reimbursement Plan (MERP) Claim Form (PDF - 61.5 KB)
This form should be used when a covered employee or dependent wishes to request reimbursement from their MERP.
Satisfaction Survey (PDF - 256.9 KB)
Section 125 213d eligible expenses (PDF - 152.8 KB)
Eligible expenses under 213d
Supplemental Accident Questionnaire (PDF - 51 KB)
This form is required for claims related to an accident. Please complete and return to Significa Benefit Services.