Health Claim Form

To submit a manual claim, complete an insurance Health Claim Form, attach the original receipts and documents, and mail to the insurer. Remember to keep a copy of all original documents for your records.

The following information is required on the claim form:

Plan Number: 12356
Division Number: Not Applicable Leave Blank
Plan Name: SCHOOL
Employee Identification Number: Your Student ID
Employee Name: Your Name
Address: Your Current Mailing Address

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