Provider Forms

Dental Claim Form
This form is used to submit a dental claim.

Disability Claim Form
This form is used to submit a disability claim.

Health Plan Claim Form
This form may be used to submit a group health plan claim, however claim forms are not required.

Supplemental Accident Questionnaire
This form is required for claims related to an accident. Please complete and return to Significa Benefit Services.

third party administrator provider forms