Automatic Payment Form

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

Automatic Payment Form (Spanish)

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

PHI Release Authorization Form

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

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.

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.

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