Submit claims online
Find and complete a healthcare, dentalcare, visioncare and life and accidental death and dismemberment claim form.
Claims and COVID-19
Due to the uncertainty of the evolving COVID-19 situation, there could be delays in processing and paying paper claims. Before you submit a paper claim, check if you can submit your claim online through GroupNet for plan members. It’s the fastest way to ensure we can process and pay your claim. Sign in and select make a claim and choose your claim type.
Please note that disability claims can’t be submitted through GroupNet. For these claims, see COVID-19 claims or standard claims.
You can submit many of your healthcare claims through GroupNet, our secure online group benefits website.

- Healthcare claim form - 151 kb M635D Opens in a new window pdf Opens in a new window
- Healthcare expenses statement - 143 kb M635D(HCSA-W) Opens in a new window pdf Opens in a new window
- Health SolutionsPlus - 516 kb M635D(HSPT-W) Opens in a new window pdf Opens in a new window
- Nursing care health assessment form - 319 kb E1083A Opens in a new window pdf Opens in a new window
- Wellness/lifestyle account expenses statement - 130 kb M7464 Opens in a new window pdf Opens in a new window
- Pre-treatment/estimate for continuous glucose monitor (CGM) - 204 kb M7463 Opens in a new window pdf Opens in a new window
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Positive Airway Pressure Machine Assessment Form - 147 kb M7476(PAP)
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Use this form to request coverage for a positive airway pressure machine. You’ll need the doctor to fill it out.
pdf Opens in a new window - Medical reimbursement plan (MRP/cost-plus) expense statement (Group Authorized) - 109 kb M6735(GA) Opens in a new window pdf Opens in a new window
- Medical reimbursement plan (MRP/cost-plus) expense statement (direct submit) - 134 kb M6734(D) Opens in a new window pdf Opens in a new window
- Dentalcare claim form - 196 kb M445D(WPG) BIL Opens in a new window pdf Opens in a new window
- Dentalcare expense statement (with healthcare spending account) - 205 kb M445D(HCSA-W) Opens in a new window pdf Opens in a new window
- Health SolutionsPlus - 202 kb M445D(HSPT-W) Opens in a new window pdf Opens in a new window
During the COVID-19 outbreak, please email us these forms or fax them. You’ll find this info on the forms.
- Accidental dismemberment or specific loss - 133 kb M4437 Opens in a new window pdf Opens in a new window
- Specific loss supplementary benefits claim form - 65 kb M6710 Opens in a new window pdf Opens in a new window
- Certificate of attending physician - 142 kb M4442 Opens in a new window pdf Opens in a new window
- Life waiver - employee's statement - 376 kb M4811 Opens in a new window pdf Opens in a new window
- Life waiver - employee's authorization only - 118 kb M4811(EA) Opens in a new window pdf Opens in a new window
- Group life claimant statement - 77 kb M62 Opens in a new window pdf Opens in a new window
- Attending physician's certificate of death - 117 kb M63 Opens in a new window pdf Opens in a new window
- Group life insurance advance payment request form - 190 kb M7354(1) Opens in a new window pdf Opens in a new window