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CLAIM FORMS

When available, the fastest and simplest way to submit your claim is filing online with the Online Form.

General Forms (English)

Form Name
Online Form
Paper Size
 
 
8.5x11
A4
Appeals Form
Appeal Form 8.5 x 11
Appeal Form A4
Application Form for Individual Coverage
 
Application Form Individual 8.5 x 11
Application Form Individual A4
Attending Physician Statement
 
Attending Physician Statement 8.5 x 11
Attending Physician Statement A4
Catlin Claim Form
 
Catlin Claim Form 8.5 x 11
N/A
Dental Claim Form
Dental Claim Form 8.5 x 11
Dental Claim Form A4
Diabetic Medical Questionnaire
 
Diabetic Medical Questionnaire Form 8.5 x 11
Diabetic Medical Questionnaire Form A4
Direct Billing Request Form
 
Direct Billing Request Form 8.5 x 11
Direct Billing Request Form A4
Disability Claim Form With Instructions
 
Disability Claim Form With Instructions 8.5 x 11
Disability Claim Form With Instructions A4
Electronic Deposit and Wire Transfer Form
Electronic Deposit and Wire Transfer Form 8.5 x 11
Electronic Deposit and Wire Transfer Form A4
Enrollment Form (Group)
 
Enrollment Form Group 8.5 x 11
Enrollment Form Group A4
FAQ (Frequently Asked Questions)
 
FAQ (Frequently Asked Questions) 8.5 x 11
FAQ (Frequently Asked Questions) A4
Global 360 Latin America Application Form for Individual Medical Coverage
 
Global 360 Latin America Application Form for Individual Medical Coverage 8.5 x 11
Global 360 Latin America Application Form for Individual Medical Coverage A4
Health, Wellness and Vision Claim Form
Health, Wellness and Vision Claim Form 8.5 x 11
Health, Wellness and Vision Claim Form A4
Hypertension Medical Questionnaire
 
Hypertension Medical Questionnaire 8.5 x 11
Hypertension Medical Questionnaire A4
Life Claim Form With Instructions
 
Life Claim Form With Instructions 8.5 x 11
Life Claim Form With Instructions A4
Life Insurance Beneficiary Form
 
Life Insurance Beneficiary Form 8.5 x 11
Life Insurance Beneficiary Form A4
Maternity Questionnaire
Maternity Questionnaire 8.5 x 11
Maternity Questionnaire A4
Medical Accident Questionnaire
Medical Accident Questionnaire 8.5 x 11
Medical Accident Questionnaire A4
Medical Release Form
Medical Release Form 8.5 x 11
Medical Release Form A4
Personal Representative Appointment
Personal Representative Appointment 8.5 x 11
Personal Representative Appointment A4
Preauthorization Form
Preauthorization Form 8.5 x 11
Preauthorization Form A4
Skin Lesion Removal Questionnaire
 
Skin Lesion Removal Questionnaire 8.5 x 11
Skin Lesion Removal Questionnaire A4
Transition Of Care Application Form
 
Transition Of Care 8.5 x 11
Transition Of Care A4

General Forms (Chinese)

Form Name
Online Form
Paper Size
 
 
8.5x11
A4
Appeals Form
 
Appeal Request Form 8.5 x 11
Appeal Request Form A4
Claims Form
 
Health Claim Form 8.5 x 11
Health Claim Form A4
Direct-Billing Provider List in Greater China
 
Direct Billing Provider List Greater China 8.5 x 11
Direct Billing Provider List Greater China A4
Group MHS (General Forms)
 
Group Member Health Statement 8.5 x 11
Group Member Health Statement A4
How to File a Claim (General Information on Claims)
 
How To File A Claim 8.5 x 11
How To File A Claim A4
Instruction of Using Smart Cards (Group)
 
Instructions For Using Smart Card 8.5 x 11
Instructions For Using Smart Card A4
Pre-Authorization Flow Chart
 
PreAuthorization Flow Chart 8.5 x 11
PreAuthorization Flow Chart A4
Pre-Authorization Forms
 
PreAuthorization Request Form 8.5 x 11
PreAuthorization Request Form A4

General Forms (Portuguese)

Form Name
Online Form
Paper Size
 
 
8.5x11
A4
Health, Wellness and Vision Claim Form
Health, Wellness and Vision Claim Form Portuguese 8.5 x 11
Health, Wellness and Vision Claim Form Portuguese A4
Travel Claim Form
TravelCare Claim Form Portuguese 8.5 x 11
TravelCare Claim Form Portuguese A4

General Forms (Spanish)

Form Name
Online Form
Paper Size
 
 
8.5x11
A4
Disability Claim Form With Instructions
 
Disability Claim Form With Instructions Spanish 8.5 x 11
Disability Claim Form With Instructions Spanish A4
General Information On Claims
 
How to File a Claim Spanish 8.5 x 11
How to File a Claim Spanish A4
Global 360 Latin America Application Form for Individual Medical Coverage
 
Global 360 Latin America Application Form for Individual Medical Coverage 8.5 x 11
Global 360 Latin America Application Form for Individual Medical Coverage A4
Health, Wellness and Vision Claim Form
Health, Wellness and Vision Claim Form Spanish 8.5 x 11
Health, Wellness and Vision Claim Form Spanish A4
Life Claim Form With Instructions
 
Life Claim Form With Instructions Spanish 8.5 x 11
Life Claim Form With Instructions Spanish A4
Life Insurance Beneficiary Form
 
Life Insurance Beneficiary Form Spanish 8.5 x 11
Life Insurance Beneficiary Form Spanish A4
Skin Lesion Removal Questionnaire
 
Skin Lesion Removal Questionnaire Spanish 8.5 x 11
Skin Lesion Removal Questionnaire Spanish A4
Travel Claim Form
TravelCare Claim Form Spanish 8.5 x 11
TravelCare Claim Form Spanish A4

General Forms (Japanese)

Form Name
Online Form
Paper Size
 
 
8.5x11
A4
Claim Form - Provider's Verification
 
Health, Wellness and Vision Claim Form Portuguese 8.5 x 11
Health, Wellness and Vision Claim Form Portuguese A4
Preauthorization Form
 
Preauthorization Form Portuguese 8.5 x 11
Preauthorization Form Portuguese A4

Student Insurance Forms

Form Name
Online Form
Paper Size
 
 
8.5x11
A4
Student Insurance Appeal Form
 
StudySafe Appeal Form 8.5 x 11
StudySafe Appeal Form A4
Student Insurance Claim Form
 
StudySafe Claim Form 8.5 x 11
StudySafe Claim Form A4
Student Insurance Pregnancy Verification Form
 
StudySafe Pregnancy Verification Form 8.5 x 11
StudySafe Pregnancy Verification Form A4
Student Insurance Medical Accident Questionnaire
 
StudySafe Appeal Form 8.5 x 11
StudySafe Medical Accident Questionnaire A4

Safe Travels Forms

Form Name
Online Form
Paper Size
 
 
8.5x11
A4
Safe Travels Medical Claim Form
 
Safe Travels Medical/Baggage Claim Form 8.5 x 11
Safe Travels Medical/Baggage Claim Form A4
Safe Travels Trip Claim Form
 
Safe Travels Claim Form 8.5 x 11
Safe Travels Claim Form A4

Travel Forms

Form Name
Online Form
Paper Size
 
 
8.5x11
A4
Group Travel Application Form
 
Group Travel Application Form 8.5 x 11
Group Travel Application Form A4
Travel Claim Form
TravelCare Claim Form 8.5 x 11
TravelCare Claim Form A4
Travel Claim Form (Spanish)
TravelCare Claim Form Spanish 8.5 x 11
TravelCare Claim Form Spanish A4
Travel Claim Form (Portuguese)
TravelCare Claim Form Portuguese 8.5 x 11
TravelCare Claim Form Portuguese A4
Travel Claim Form (German)
TravelCare Claim Form German 8.5 x 11
TravelCare Claim Form German A4
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