Claim Forms
- Form 41
Complete this questionnaire in full when you or a covered family member have:- coverage under any other health plan
- automobile insurance that pays health care expenses without regard to fault
- Medicare coverage
- a workplace-related illness or injury
- Member Claim Form
Complete this claim form to submit your covered medical expenses to the Plan. See How to File a Claim.
- Form J400
Complete this claim form to submit your covered dental accident expenses to the Plan.
- Form
SP190
Complete this form if you or a dependent has been involved in an accident or contracted an illness caused by a third party.
