Indemnity Plan Forms
Accidental Dismemberment Claim Form
Accidental Dismemberment Claim Form-Spanish
Accidental Dismemberment Claim Form (Physician's Statement)
Accidental Loss of Limb or Sight Claim Form
Accidental Loss of Limb or Sight Claim Form-Spanish
Accidental Loss of Limb or Sight Claim Form-Physician's Statement
Covid Testing Member Reimbursement 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 Claim Form
Short-Term Disability / Proof of Loss Claim Form-Spanish
Term Life / Accidental Loss of Life Claim Form
Term Life / Accidental Loss of Life Claim Form-Spanish