Dental Claim Form (PDF - 150.2 KB)
This form is used to submit a dental claim.
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Disability Claim Form (PDF - 78.6 KB)
This form is used to submit a disability claim.
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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.
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Supplemental Accident Questionnaire (PDF - 51 KB)
This form is required for claims related to an accident. Please complete and return to Significa Benefit Services.
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