Forms


Download and Use the Following Forms


The following online forms are available for you to download and use.

You will need the latest version of Adobe© Acrobat© Reader that can be obtained here.

Forms for Employees


  Accident Information Form (30K)
CVS/Caremark Reimbursement Claim Form (95K)
Dependent Health Statement (130K)
Dental and Vision Claim Form (32K)
Mail Order Prescription Plan Sign-Up (450K)
Medical Claim Form (39K)
Other Insurance Inquiry (interactive form)
Personal Health Statement (503K)
Short Term Disability Claim Form (86K)

Forms for Clubs


  Club Participation Agreement (63K)
Employee Application & Coverage Change Form (97K)
Employee Termination Notice (22K)
Medical Claim Form (34K)
 
 
  • Request a Quote
  • Find a Provider
  • Verify Coverage
  • Nurse Line
  • Filing a Claim
Boys & Girls Club Workers Association