Please complete the form below in order to avoid delays in processing your claims and mail it to:
If you and your dependents are enrolled in another medical plan, please indicate below any other coverage. This would include coverage through an employer, a spouse's plan, a parent's plan, Medicaid, Medicare, etc.
If you have any questions, contact us at 1-800-247-7114. Our customer service representatives are available Monday through Friday from 8 a.m. to 6 p.m. Central Standard Time.