Member Claim Forms

Use these forms to submit claims.


Claim Forms

Dental Claim Form

Use this form to submit claims and expenses for preventive dental care you received. 

Member Claim Form

Use this form to submit claims and expenses for medical care or a drug you received.

Vision Claim Form

Use this form to submit claims and expenses for routine vision care you received.

Updated October 1, 2019
H9408_WBST20