Corporate Information

Forms Library

  
Health Plan Claim Form
This form is used to verify employee eligibility for group health plan coverage. This form may also be used to submit a group health plan claim, however claim forms are not required.
Dental Claim Form
This form is used to submit a dental claim.
Disability Claim Form
This form is used to submit a disability claim.
Health Reimbursement Arrangement Claim Form (HRA)
This form should be used when a covered employee or dependent wishes to request reimbursement from their HRA.
Medical Expense Reimbursement Plan (MERP) Claim Form
This form should be used when a covered employee or dependent wishes to request reimbursement from their MERP.
Flexible Spending Account Claim Form
This form is required to be submitted with all FSA claims. Be sure to include the Explanation of Benefit (EOB) from the plan (medical, dental, etc.).
Supplemental Accident Questionnaire
This form is required for claims related to an accident. Please complete and return to Significa Benefit Services.
Designation of Personal Representative
This form should be used when a covered employee or dependent wishes to designate an authorized personal representative to have access to their claim information and other personal health information.
Full-time Student Verification Form
This form can be downloaded and sent to the student's college or university. It should be completed by the school to verify a student is full-time.
Coordination of Benefits Form/Duplicate Coverage Inquiry Form
This form is required at least once per year to verify if dependents have "other coverage." This form should also be submitted when changes in coverage occur.
COBRA Administration Form
This form is used to determine any other coverage for an individual who has elected COBRA.