Indemnity Plan Forms
Accidental Death & Dismemberment Claim Form
Accidental Death & Dismemberment Claim Form-Spanish
Accidental Dismemberment Claim Form (Physician's Statement)
Accidental Dismemberment Claim Form (Physician's Statement)-Spanish
Accidental Loss of Life, Limb or Sight Form
Accidental Loss of Life, Limb or Sight Claim Form-Spanish
Accidental Loss of Limb or Sight Claim Form-Physician's Statement
Accidental Loss of Limb or Sight Claim Form-Physician's Statement-Spanish
Authorized Representative Form
Authorized Representative 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
Termination / Loss of Coverage Form
Termination / Loss of Coverage Form-Spanish
Vision Out of Network Claim Form
Vision Out of Network Claim Form-Spanish