Download forms

Frequently used forms

• Dental claim form
• Disabled dependent declaration
• Health benefits claim form (includes vision)
• Health Spending Account (HSA) claim form
• Pre-authorization request form

Specialty claim forms

• Accidental dental claim form
• Ambulance/medical transfer claim form
• Assisted care nursing recommendation claim form
• Glucose monitoring special authorization request form
• Hospital claim form
• Orthotics, orthopedic shoes and modifications claim form

Bank forms

• Direct deposit application form
• Pre-authorized debit form (for individuals)
• Provider direct deposit form (for providers only)

Travel forms

• For emergency health claims: Travel Insurance claim form
• For trip cancellation claims: Trip Cancellation Insurance claim form
• For baggage claims: Baggage Benefit claim form

Disability benefit forms

To submit an application for disability benefits, an employee’s statement, employer’s statement AND attending physician’s statement are required.

• Employee’s statement
• Employer’s statement (including a Job analysis form or a detailed job description)
• Attending physician’s statement (short-term disability – weekly indemnity OR long-term disability)
• Direct deposit authorization form

Learn more about our disability claims appeals process.

Group life forms

• Group life benefit claim form

Critical illness forms

To submit an application for critical condition benefit, two forms are required:

• Application for critical condition benefit
• Attending physician’s statement

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