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    December 22, 2010      

 

 

Claim Forms

Form 41

Complete this questionnaire in full when you or a covered family member have:

  • coverage under any other health plan
  • automobile insurance that pays health care expenses without regard to fault
  • Medicare coverage
  • a workplace-related illness or injury

HCFA 1500

Complete this claim form to submit your covered medical expenses to the Plan.

Form J400

Complete this claim form to submit your covered dental accident expenses to the Plan.