Forms for Group Benefits Plan Members

Note: You can also access the most common forms online, personalized and pre-filled for you, through our GroupNet™ for Plan Members secure site.

Claim Forms

• Standard claim forms
• Ambassador, CANUS and Welcome Plan claim forms
• Group Critical Illness claim forms
• Out-of-Country claim forms
• Health SolutionsPlus claim forms

Other Forms

• Application and evidence forms
• Prior Authorization forms

• Direct Deposit form

• Request for Brand Name Drug Coverage form

Instructions for Making a Claim

Note: Many of the forms can be completed on-screen, by clicking in the space provided for writing and typing in your information. Once you have completed the form, print, sign and date it, and mail it to us.

1. Print the appropriate claim form and complete all sections.
2. Ensure your form is signed and dated.
3. Mail the form, plus all receipts (originals only), to the address indicated in your benefits plan booklet, or contact your plan administrator for the correct address.

Incomplete forms may be returned to you, which could delay the processing of your claim.

If you’re a group plan administrator looking for enrollment and administration forms, go to the Client Services - Group Plan Administrators page.

The documents on this Web page are in PDF format. To view and print these documents, you will need Adobe Acrobat Reader Version 4.0 or higher, which you can download, at no cost, from the Adobe website.