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 (PDF - 72.9 KB)
This form is required at least once per year to verify if dependents have other coverage.
Debit Card Pin Number (PDF - 177 KB)
Instructions for obtaining a Debit Card Pin Number
Dental Claim Form (PDF - 172.7 KB)
This form is used to submit dental claims
Designation of Personal Representative (PDF - 104.9 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 - 139.7 KB)
This from is used to submit a disability claim
EOB Sample (PDF - 65.6 KB)
Explanation of Benefits
Flexible Spending Account Claim Form (PDF - 149.4 KB)
FSA Claim form
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 - 106 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 - 135.7 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)
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 - 51 KB)
This form is required for claims related to an accident. Please complete and return to Significa Benefit Services.