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Claim Forms

Online Claim Forms

Click the appropriate link and you will access an online form.

OPTIMED PRODUCT CLAIM FORMS

OptiMed GAP

OptiMed GAP Rx

Limited Med How to Video

Limited Med Rx

Minimum Essential Coverage (MEC) How to Video

Vison (aversis)

DENTAL CLAIM FORMS

FSL (Fidelity Security Life)

Nationwide Product Downloadable Claim Forms

Download onto computer. Forms can be filled out digitally using Adobe Acrobat or other PDF software but will not be fillable in most web browser preview windows.

NOTE: While the forms are “fillable,” they can not be submitted digitally unless you scan and email to the address provided on the form (If there is one).

LIFE AND AD&D CLAIMS FORMS

Employer Guide to Naming a Life and AD&D Benificiary

Designation of Beneficiary Form

Life Accidental Death Claim Form

Additional AD&D Benefits Claim Form

Accelerated Death Benefit

Accidental Dismemberment or Specific Loss

Accelerated Death Benefit Disclosure State

Waiver of Premium or Continuation of Benefit Form

CASHBACK CLAIM FORMS

Supplemental Accident Claim Form

Hospital Indemnity Claim Form

Ohio Hospital Indemnity

DISABILITY CLAIM FORMS

Disability Claim