Pages Navigation Menu

Commonly Requested Forms

We’ve provided access to some commonly used forms. If you aren’t sure which you should use or don’t see the form you are looking for, please contact our Claim Department at 800-371-9622.

Please note: These forms are related ONLY to Health, Dental, Life, and Disability coverage. They are not applicable to any type of auto, homeowners, workers compensation, or any other non-health-related coverages. For assistance with those types of claims, please contact 888-735-4611.

Authorization to Disclose Medical Information for Customer Service LS253 We are only authorized to discuss health information with you unless you provide authorization for us to discuss matters with someone else. Any insured over the age of 17 must complete this form if they wish to authorize anyone to access their claim information for customer service purposes.

Authorization for Use or Disclosure of PHI LS264 This form will need to be completed if we need to obtain records from your health care provider. It will give us authorization to get the records needed to process your claims.

Claim Form LC106 Used when additional medical history information is needed on a claim. This form is NOT needed for most claim filings. Only complete this form if we’ve requested it from you on a claim.

Disability Statement of the Insured LC171 Disability forms are used to file a claim for Individual disability income benefits or Group weekly benefits. You may contact the Life Claim Department at 800-371-9622 to discuss your claim.

Insured Supplemental Statement LC142 (Group Disability) Used to provide updated proof of continual disability on a disability claim currently in benefit.

Accidental Injury Report LG199 For claims related to an accidental injury, additional information is typically needed in order for us to process your health insurance claim. This form is used for accident claims being filed under a Major Medical Plan.

Call Toll-Free 1-800-322-0160