Claim Forms

Cancer and Disability Claim Form
Use this form to claim benefits under a cancer policy or a disablility policy.

Life Insurance Claim Form
Use this form to file a life insurance claim.

Final Expense-Funeral Home Claim Form
Use this form if you have a Final Expense-Funeral Home policy.

Dental, Vision & Hearing Claims
 
How to file a claim for your Dental, Vision & Hearing Policy 
Click the link for more information about how to file a claim form for Dental, Vision & Hearing.

Vision Claim Forms
Policy Numbers that begin with "77" 
Policy Numbers that begin with "00M1D"

Vision Claim Forms for North Carolina Residents
Policy Numbers that begin with "77" 
Policy Numbers that begin with "00M1D" 

Hearing Claim Forms
Policy Numbers that begin with "77" 
Policy Numbers that begin with "00M1D" 

Hearing Claim Forms for North Carolina Residents
Policy Numbers that begin with "77" 
Policy Numbers that begin with "00M1D" 

Hospital Indemnity Claims

How to File a Claim for your Hospital Indemnity Policy
Click the link for more information about how to file a claim form for a Hospital Indemnity policy.

Medicare Supplement Claims

Your health care providers will usually submit electronically to Medicare the billed charges for any Medical and Hospital expenses you incur. Medicare then processes benefits for expenses eligible under Part A and/or Part B of Medicare, and passes your claim electronically to us for consideration of benefits under your Medicare supplement policy. We will accept Medicare’s electronic submission of your claim to us as your notice of claim. For consideration of expenses that are not submitted electronically to us, a paper copy of your Medicare Summary Notice or Medicare Benefit Notice can serve as your notice of claim. This Medicare statement shows your Medicare Eligible Expenses and the amount approved and paid by Medicare. You may submit a paper copy of your Medicare statement to us or your health care provider may submit it to us on your behalf. If your claim is submitted electronically the requirements for claim forms and proof of loss will be met. 

Short-Term Care Claims

Short-Term Care Claim Form
Use this form to claim benefits under a short-term care policy.

Short-Term Care Attending Physician's Statement
This form is used for short-term care policy forms NHA06, NHA07, or NHA30 purchased in 2006 or later. It is a form that must be completed and submitted by the attending physician.

Short-Term Care Facility Certification of Care
This is a form for those NHA06, NHA07, or NHA30 policyholders who are moving from one facility to another or who are going into a facility for the first time. Staff from the facility need to complete and submit this form.

Short-Term Care Monthly Verification of Continuing Care
This is a form to be completed by facility staff. This form is used to verify continuing care for NHA06, NHA07, or NHA30 policyholders. It must be submitted each month with the billing.

Claimant's Supplemental Report
This is a form to be completed by facility staff. This form is used to verify continuing care for NHA06, NHA07, or NHA30 policyholders. It must be submitted each month with the billing.

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