Resources

File an Insurance Claim

Please Download and Complete the Form Email Completed form to [email protected]

Prescription Reimbursemen

Take a picture of the receipt on the bag.
Include your policy#Bullet List 3

Self Pay Claim Form

Used when you paid a medical provider directly — without using your insurance — and want to file for reimbursement. No signature is required to submit this form.

Download the Self Pay Claim Form PDF.
Complete all fields — include provider name, date of service, and amount paid.
Attach receipts or provider statements, then email everything to the claims address.

GAP Medical Claim Form

GAP coverage pays the difference between what your primary insurance covers and your actual medical bill — such as deductibles, co-pays, and co-insurance after a hospital stay or surgery.

Download the GAP Medical Claim Form PDF.
Attach your Explanation of Benefits (EOB) from your primary insurer showing what was paid and what you owe.
Complete and email the form with all supporting documents.

Accident Claim Form

File this form if you received medical treatment following an accidental injury — such as a fall, car accident, or sports-related injury — and want to claim your accident benefit.

Download the Accident Claim Form PDF.
Describe the accident — date, cause, and nature of injury in the form fields.
Attach itemized medical bills and any emergency room or urgent care records, then email.

Critical Illness Claim

f you've been diagnosed with a covered critical illness — such as cancer, heart attack, or stroke — this form initiates a lump-sum cash benefit paid directly to you, regardless of other insurance.

Download the Critical Illness Claim Form PDF.
Have your physician complete the attending physician section confirming the diagnosis.
Submit the signed form along with diagnosis records and pathology reports by email.

Medical Expense Claim

Use this form for general covered medical expenses — including doctor visits, lab work, imaging, or specialist appointments — that fall within your plan's benefit schedule.

Download the Medical Expense Claim Form PDF.
Complete all patient and provider fields — include date of service, diagnosis code, and amount billed.
Attach itemized provider bills and email the completed package to the claims address

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