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Standard Claim Forms

The mailing address for claims or correspondence is provided on the claim form.  Select the applicable form to locate the mailing address.

If you’re a group benefits plan administrator and you’re looking for forms, go to the Client Services – Group Benefits Plan Administrators page.

Healthcare

Dentalcare

Visioncare

Prescription Drug Claims

These forms are for plan members with an Assure Card. Select the form that corresponds to the office where you normally send your healthcare claims:

Disability

Life and AD&D

These documents are in PDF format. To view and print them, you need Adobe Acrobat Reader version 5.0 or higher and some forms require Adobe Acrobat XI. If you don’t have Adobe Acrobat Reader or need to upgrade your version, you can download it, at no cost, from the Adobe website.

GroupNet for Plan Members

Keeping Costs Down

Find out how you can help protect your benefits plan from rising costs.


Questions?

Contact your plan administrator, or go to our Contact Information – Coverage and Claims Status page.

Need to Make Changes?

To update your personal information, contact your plan administrator.