FORMS

2019 PCP Physical Form
HSA Direct Deposit Form

Allstate – Online Policy Access and Electronic Claim Filing
Allstate Wellness Claim Form (Critical Illness & Cancer Policies)
Allstate Accident Plan Office Visit Claim Form
Allstate Accident Claim Form
Allstate Cancer Policy Claim Form
Allstate Critical Illness Policy Claim Form
EyeMed Out-of-Network Claim Form
Flexible Spending Debit Card Substantiation Form
Flexible Spending Direct Deposit Form
Flexible Spending Qualifying Events Form
Flexible Spending Reimbursement Request Form
Life Insurance Evidence of Insurability Form (EOI)
Rx Claim Form – OptumRx
Voluntary Short Term & Long Term Disability Insurance Claim Form
Voluntary Short Term & Long Term Disability Cancellation Form
VOYA Life Conversion Form
VOYA Life Portability Form
VOYA Life Porting Rates
VOYA Travel Assist Info.
VOYA LTD Attending Physician’s Statement claim form
VOYA LTD Claim Form (county paid plan)