Forms

Health Benefit Claims Forms

• CVS Prescription Mail Order Form
• National Vision Administrators Claim Form
• Member Submitted Claim Form
• WEX Claim Form
• Reliance Matrix Accident Insurance/Critical Illness Insurance Claim Form
• Reliance Matrix Wellness Claim Form 
• Unum Critical Illness Plan Claim Form  – For Claims Prior to 8/1/2024
• Unum Accident Protection Plan Claim Form – For Claims Prior to 8/1/2024
• Unum Be Well Benefit Claim Form  – For Claims Prior to 8/1/2024