Forms
Online forms — access online forms by logging into My Account, then fill out the brief online form and you're done. You'll be notified by email when we receive your request. Printable forms — print your form, complete the appropriate sections, and then mail it to us. To open and view the printable forms, you will need Adobe Reader.
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descriptionAccident Insurance Claim FormdescriptionAdd Household Discount to Medicare Supplementaccount_circleAddress ChangedescriptionAddress ChangedescriptionAge Correctionaccount_circleAutomatic Bank WithdrawaldescriptionAutomatic Bank WithdrawaldescriptionBeneficiary FormdescriptionBilling Statement ReplacementdescriptionCollateral Assignment FormdescriptionDental Claim Appeal/Grievance FormdescriptionDental Insurance Claim FormdescriptionDental NY Designate a RepresentativedescriptionDuplicate Copy of Insurance PolicydescriptionHIPAA AuthorizationdescriptionHospitalization/Cancer Insurance Claim FormdescriptionID Card ReplacementdescriptionLife Insurance Claim FormdescriptionLife Ownership Change RequestdescriptionLong-Term Care Assignment BenefitsdescriptionSubmit Long Term Care ClaimdescriptionLong-Term Patient Care Flow SheetdescriptionLong-Term Plan of Care TreatmentdescriptionMedicare Supplement Insurance Claim FormdescriptionMedicare Supplement Discount Form for New DentaldescriptionName ChangedescriptionNext of KindescriptionPet Insurance Cancellationaccount_circleRequest a Billaccount_circleRequest a Duplicate Copy of Insurance Policyaccount_circleRequest a Replacement Health ID Card