Forms

If you need assistance completing any forms or have any questions, please call Customer Service at 1-866-740-4006. Representatives are available Monday through Friday, 8:30 a.m. to 8:00 p.m. Eastern Time. A language line is available for translation for most languages.

General Forms

Accidental Loss of Limb or Sight Claim Form

Authorized Representative Form / Formulario de Representante Autorizado

Critical Illness Claim Form

Medical Claim Form / Formulario de Reclamo de Gastos Médicos

Prescription Drug Reimbursement Claim Form

Hospital Indemnity Claim Form (VOYA)

Term Life-Accidental Loss of Life Claim Form

Wellness and Preventive Reimbursement Claim Form

Discounts

PAI HIPAA Forms

HIPAA-all groups