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To report new claim(s) click below

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To access previously reported claim(s) click below

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New Claims
To enter new claims, please enter your Plan Number and press tab:
Plan Number:
Enrollment ID: (optional)

Please indicate if you are a(n):

Prefix         Your First Name                Your Last Name
    

Have you previously reported a claim? Yes   No
Claim ID:  
Report New Claim

Existing Claims
To access existing claims, please enter your Plan Number, First and Last Name (exactly as entered on your claim form), your Date of Birth, and the Claim ID: (all fields are required to access your existing claim)

Plan Number:  
First Name:  
Last Name:  
Date Of Birth:  
Claim ID:  
Edit Existing Claim

 
To view and or print claim forms, you will need Adobe Acrobat Reader 8.0 or later. If you have an earlier version, you will need to save the file prior to view/printing.