Indemnity Plan Forms
Accidental Dismemberment / Loss of Sight Claim Form
Accidental Dismemberment / Loss of Sight Claim Form-Spanish
Accidental Dismemberment / Loss of Sight Claim Form-Physician
Covid Testing Member Reimbursement Form
EyeMed Out of Network Vision Services Claim Form
Missed Premium Direct Payment Form
Missed Premium Direct Payment Form-Spanish
Prescription Drug Reimbursement Claim Form (Use this form if Rx group RxGRP: DISCOUNT is on your ID card.)
Prescription Drug Reimbursement Request Form (OptumRx) (Use this form if Rx group BXPAI is on your ID card. If you medical plan entitles you to pay a co-pay at the point of purchase and your prescription was not filed directly to OptumRx by the pharmacy, use this form to submit payment. If your medical plan entitles you to a discount at the point of purchase, and you file your receipts to PAI for reimbursement, please use the form above.)
Short-Term Disability / Proof of Loss Form
Short-Term Disability / Proof of Loss Form-Spanish
Term Life / Accidental Loss of Life Claim Form
Term Life / Accidental Loss of Life Claim Form-Spanish
MEC Plan Forms
Covid Testing Member Reimbursement Form
MEC Medical Claim Form-Spanish
MEC Missed Contribution Direct Payment Form-for MEC Weekly Plans
MEC Prescription Drug Reimbursement Claim Form