Member Forms

COBRA Administration Form
This form is used to provide information about other coverage a COBRA participant may have to assure coordination of payments.

Debit Card Pin Number
This is a set of instructions for obtaining a Debit Card Pin Number.

Dental Claim Form
This form is used to submit claims for dental expenses under a dental plan.

Designation of Personal Representative
This form must be provided 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
This form is used to submit claims for income replacement under a short term disability plan.

EOB Sample
This is a sample Explanation of Benefits form.

Flexible Spending Account Claim Form
This form is used to submit claims for medical expenses under a health care flexible spending arrangement and dependent care expenses under a dependent care flexible spending arrangement.

third party adminstrator member forms

Health Reimbursement Arrangement (HRA) Claim Form
This form is used to submit claims for expenses under a health reimbursement arrangement.

Medical Claim Form
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
This form is required at least once per year to verify if dependents have other coverage.

Satisfaction Survey

SBC Uniform Glossary
This is a uniform glossary of terms commonly used in health insurance coverage.

Code Sect 213(d) Eligible Expenses
This is a listing of common IRS Section 213(d) eligible reimbursable expenses.

Supplemental Accident Questionnaire
This form is required for claims related to an accident.