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E-mail a Question to the Claims Department

Please complete and submit the form below. You will receive an e-mail reply by noon (central time zone) the next business day.

NOTE: This form is for policy/certificate holders only. Medical/Dental Providers should call 1-800-256-8606.

Policy / Coverage Information

Type of Coverage:
Health Dental

Policy/Certificate Number:

Primary Insured/Employee/Subscriber:

First Name:

MI:

Last Name:

Mailing Address:
Street:

City:

State:

Zip Code:

Claimant / Contact Information

Claim is on:

First Name:

MI:

Last Name:

Your Name (if you are not the claimant):

First Name:

MI:

Last Name:

Your relationship to the claimant:

Your daytime telephone number:

Your e-mail address:

Your question:

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