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Form

 

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Subscriber's Statement of Claim

 

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Authorization for Release of Personal and Health Information

 

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Prescription Drug Reimbursement Form

 

English
Spanish

Blue Shield Global Core International Claim

 

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Proof of Death Form: Group Life

 

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Accelerated Death Benefit Claim Form: Group Life

 

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Dismemberment Claim Form: Group Life

 

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Dental Claim

 

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Vision Claim

 

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Waiver of Premium Claim Form: Group Life
If a member becomes totally disabled, the life premium may be waived.

 

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Beneficiary Affidavit & Assignment Form

 

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Beneficiary Change Request

 

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Form

 

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Conversion to Individual Coverage: Group Life

 

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Beneficiary Affidavit (life insurance groups of 10 or more)

 

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Beneficiary Change Request Form

 

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Form

 

DOI  

English  |  Spanish

DMHC  

English  |  Spanish  |  Chinese  |  Hindi  |  Vietnamese  |  Korean
*Translations temporarily unavailable.
**Underwritten by Blue Shield of California Life & Health Insurance Company.