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    January 18, 2008      

 

 

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.