Information

Claim Forms & Worksheets

Employee Question Resolution Form


Please provide us with the following information so that someone from our staff will be able to respond to your request in a timely manner.

* Indicates a Required Field

* Employer Name
* Policy Number
* Employee Name
* Home Address
* Home Phone Number
* Work Phone Number
* Fax Number
* Social Security Number
* E-mail Address
* Patient Name
* Relationship to Employee

Your service issue deals with what type of insurance plan?

Medical
Dental
Cafeteria/125 Flex Plan
Life
Long Term Disability
Short Term Disability
Other

Please fll out the following information.

Date of Service
Hospital/Doctor/Specialist
Amount of Bill

What is the nature of the illness?


What is the nature of the problem?


Let us know how to respond to your request.

Telephone
E-mail
Mail
Fax