Claims & Forms

We process claim forms right away. All you need to do is find the correct form, and then scan and email, fax, or mail it to us.

Claim Forms

 

• Hospital Surgery Benefit (Wisconsin State Employees)
• Rapid Pay Income Replacement (STD): AP – Update
• Rapid Pay Income Replacement (STD) Attending Physician (AP)
• Rapid Pay Income Replacement (Short-term Disability)
• Rapid Pay Income Replacement Federal Income Tax Withholding Form
• Rapid Pay Income Replacement (STD): Employee
• Rapid Pay Income Replacement (STD): Employer
• Rapid Pay Income Replacement (STD): Right of Recovery
• Rapid Pay Income Replacement (STD): Instructions
• Short-term Disability
• Short-term Disability Federal Income Tax Withholding Form
• Short-Term Disability: Attending Physician Statement
• Short-term Disability: Attending Physician – Update
• Short-Term Disability: Employee
• Short-Term Disability: Employer
• Short-Term Disability: Instructions
• Life and AD&D
• LTD Claim Form
• Activities of Daily Living
• Premium Waiver
• Long-term Disability
• Vision

Other Forms

 

• Employer’s Group Application (for use in Wisconsin only)
• Employee’s Application for Group Coverage (for use in Wisconsin only)
• Beneficiary Designation Form
• WSE Beneficiary Designation Form
• Authorization to Disclose Health-Related Information
• Instructions for Completing the Member Authorization Form
• Appeals/Grievance Authorized Representative Form
• Complaint Form
• Notice of Privacy Practices
• Request for Access to Protected Health Information
• Instructions for Completing the Member Authorization Form
• Authorized Representative Form for Grievance/Appeal
• Fillable Authorized Representative Form for Grievance/Appeal
• Member Authorization to Release Member’s Protected Health Information (PHI)
• Authorization to use or Disclose PHI by Electronic Means
• Request for Confidential Communications of PHI
• Request for Amendment of PHI
• Privacy Complaint Form