PAI Self Funded Forms

Traditional Self Funding

​Accident Questionnaire

Accident Questionnaire-Spanish

Authorized Representative Form

Authorized Representative Form - Spanish

Benefits Enrollment/Change Form

Benefits Enrollment/Change Form-Spanish

Continuation of Care Form

Coordination of Benefits Form

Coordination of Benefits Form-Spanish

COVID-19 Testing Member Reimbursement Form

COVID-19 Testing FAQs

Dental Claim Form

Employee Termination Form

Mail Order Prescription Form (Optum Rx)

Mail Order Prescription Form (Optum Rx)-Spanish

Medical Benefits Short-Term Disability Claim Form

Medical Benefits Short-Term Disability Claim Form-Spanish

Medical Claim Form

Medical Claim Form-Spanish

Prescription Reimbursement Request Form

Short-Term Disability Claim Form

Short-Term Disability Claim Form-Spanish

Level Funding

Level Funded Automated Risk Assessment

Level Funded EE 10-50 EE App

Level Funded EE 51+ EE App

Level Funded Employer Application

This product is not available in the state of South Carolina