Claim Forms

To download a claim form, select the state and policy type from the dropdown boxes below. Complete the form and mail it to the address provided in the form.

Please select state where care is being provided:	Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming
Please select the type of policy:	Select Policy Type Annuity Life Long Term Care / Home Health Care Medicare Supplement Initial Disability Claim Form - 458 Continuing Disability Claim Form - 2970 Senior Hospital Indemnity - Claim Form SHIP EOB Announce - Claim Form 18550 Appeal Request Form Supplemental Contract Critical Illness Facility Leave of Absence Form

Independent Caregiver Forms

For use with all private-hire independent caregivers.

The Independent Caregiver Packet includes Proof of Payment Requirements, Release of Liability, Caregiver Biographical and Qualifications information, and itemized Billing Statement and Daily Visit Notes. Click here to download.

To download the stand-alone Itemized Billing Statement and Daily Visit Notes form click here

Questions? Click here to review claims FAQ's.

Please note: These forms are PDF files. In order to view or download any PDF files, you will need Acrobat Reader software. If you do not have Acrobat Reader and wish to download it for free, click here to visit the Adobe Acrobat Reader website.