Automatic Payment Form

Purpose of form: Provides a format for automatic payments on your policy.


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Automatic Payment Form (Spanish)

Purpose of form: Provides a format for automatic payments on your policy.


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PHI Release Authorization Form

Purpose of form: Authorizes release of personal health information (PHI) for a member.


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Non-Tobacco User Affidavit (Spanish)

Purpose of form: A form  to declare if a member presently smokes or uses tobacco products, nor (ii) have smoked or used tobacco products at any time during the 12 months immediately preceding the date of the affidavit.


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Non-Tobacco User Affidavit

Purpose of form: A form  to declare if a member presently smokes or uses tobacco products, nor (ii) have smoked or used tobacco products at any time during the 12 months immediately preceding the date of the affidavit.


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For further information and assistance regarding Forms please contact Customer Service at 1-844-728-7896.