Essential StaffCARE Forms

Indemnity Plan Forms

Accidental Death & Dismemberment Claim Form

Accidental Death Dismemberment Claim Form-Spanish

Accidental Dismemberment -Physician Statement

Accidental Dismemberment -Physician Statement-Spanish

Accidental Loss of Life, Limb or Sight Claim Form

Accidental Loss of Life, Limb or Sight Claim Form-Spanish

Accidental Loss of Limb or Sight - Physician Statement

Accidental Loss of Limb or Sight - Physician Statement- Spanish

Authorized Representative Form

Authorized Representative Form-Spanish

Covid Testing Member Reimbursement Form

Dental Claim Form

Dental Claim Form-Spanish

EyeMed Out of Network Vision Services Claim Form

EyeMed Out of Network Vision Services Claim Form-Spanish

Medical Claim Form

Medical Claim Form-Spanish

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 (Optum Rx) (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 Claim Form

Short-Term Disability / Proof of Loss Form-Spanish

Term Life Claim Form

Term Life Life Claim Form-Spanish

Termination / Loss of Coverage Form

Termination / Loss of Coverage Form-Spanish

Vision Claim Form