EssentialCare Forms

Indemnity Plan Forms

Accidental Death & Dismemberment Claim Form

Accidental Death & Dismemberment Claim Form-Spanish

Accidental Dismemberment Claim Form (Attending Physician's Statement)

Accidental Dismemberment Claim Form (Attending Physician's Statement)-Spanish

Accidental Loss of Life, Limb or Sight Claim Form

Accidental Loss of Limb or Sight Claim Form-Spanish

Accidental Loss of Limb or Sight Claim Form (Attending Physician's Statement)

Accidental Loss of Limb or Sight Claim Form (Attending Physician's Statement)-Spanish

Dental Claim Form

Dental Claim Form-Spanish

Eye Exam Claim Form

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 Claim Form - Spanish (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 Claim Form

Short-Term Disability / Proof of Loss Claim Form-Spanish

Term Life Claim Form

Term Life Claim Form-Spanish

Term Life / Accidental Death Claim Form

Term Life-Accidental Death Claim Form-Spanish

Termination / Involuntary Loss of Coverage Form

Termination / Involuntary Loss of Coverage Form-Spanish

Vision Out of Network Claim Form

Vision Out of Network Claim Form-Spanish