Common Forms
This page includes only standard versions of our most-used forms. Many forms are specific to your policy or plan and aren't listed here. If you don't see what you need, please contact us or your benefits administrator.
Former Anthem Life customers should log in to get their claim forms.
| Title | Purpose | Action |
|---|---|---|
| Accident Benefit Claim Form (All states except NY) | Use this form to file an Accident insurance claim by mail, email or fax. Or log in to file this claim online. |
Download |
| Accident Benefit Claim Form (NY) | Use this form to file an Accident insurance claim in New York by mail, email or fax. Or log in to file this claim online. |
Download |
| ACH for Dental & Vision Customers Based in NY | Use this form to request and authorize an agreement for prearranged payments via Automated Clearing House. For use in New York only. |
Download |
| ACH for Dental & Vision Customers Based Outside NY | Use this form to request and authorize an agreement for prearranged payments via Automated Clearing House. |
Download |
| Anthem Life (Formerly) Claim Forms | Former Anthem Life customers should log in to get claim forms and use the Claims Service Center to file their life and disability insurance claims. |
Log In |
| Authorization to Release Health-Related Information | Authorize The Standard to release dental and/or vision insurance information to a designated recipient. |
Download |
| Authorization to Release Health-Related Information (NY) | Authorize The Standard to release dental and/or vision insurance information to a designated recipient. For use in New York only. |
Download |
| Authorization to Release Health-Related Information (Spanish - All states except NY) | Authorize The Standard to release dental and/or vision insurance information to a designated recipient. (Spanish) |
Download |
| Authorization to Release Health-Related Information (Spanish - NY) | Authorize The Standard to release dental and/or vision insurance information to a designated recipient. (Spanish) For use in New York only. |
Download |
| Colorado Paid Family and Medical Leave Bonding Packet | Complete this packet to apply for Colorado Paid Family and Medical Leave to bond with a newborn, a newly adopted or fostered child. |
Download |
| Colorado Paid Family and Medical Leave Care of Family Member Packet | Complete this packet to apply for Colorado Paid Family and Medical Leave to care for a family member with a serious health condition. |
Download |
| Colorado Paid Family and Medical Leave Military Leave Packet | Complete this packet to apply for Colorado Paid Family and Medical Leave to assist family members due to another family member’s active military duty or impending active duty abroad. |
Download |
| Colorado Paid Family and Medical Leave Own Serious Health Condition Packet | Complete this packet to apply for Colorado Paid Family and Medical Leave for your own serious health condition. |
Download |
| Colorado Paid Family and Medical Leave Safe Leave Attestation | Used to attest the need for Safe Leave, as defined on the form, when submitting a request for CO PFML Safe Leave benefits. |
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| Colorado Request for Paid Family and Medical Leave | Complete this packet to apply for Colorado Paid Family and Medical Leave Safe Leave benefits. |
Download |
| Connecticut Paid Family and Medical Leave Bonding Packet | Complete this packet to apply for Connecticut Paid Family and Medical Leave to bond with a newborn, a newly adopted or fostered child. |
Download |
| Connecticut Paid Family and Medical Leave Care of Family Member Packet | Complete this packet to apply for Connecticut Paid Family and Medical Leave to care for a family member with a serious health condition. |
Download |
| Connecticut Paid Family and Medical Leave Military Leave Packet | Complete this packet to apply for Connecticut Paid Family and Medical Leave to assist family members due to another family member’s active military duty or impending active duty abroad. |
Download |
| Connecticut Paid Family and Medical Leave Own Serious Health Condition Packet | Complete this packet to apply for Connecticut Paid Family and Medical Leave for your own serious health condition. |
Download |
| Critical Illness Benefit Claim Form (All states except NY and VT) | Use this form to file a Critical Illness insurance claim by mail, email or fax. Or log in to file this claim online. |
Download |
| Delaware Paid Family and Medical Leave Bonding Packet | Complete this packet to apply for Delaware Paid Family and Medical Leave to bond with a newborn, a newly adopted or fostered child. |
Download |
| Delaware Paid Family and Medical Leave Care of Family Member Packet | Complete this packet to apply for Delaware Paid Family and Medical Leave to care for a family member with a serious health condition. |
Download |
| Delaware Paid Family and Medical Leave Military Leave Packet | Complete this packet to apply for Delaware Paid Family and Medical Leave to assist family members due to another family member’s active military duty or impending active duty abroad. |
Download |
| Delaware Paid Family and Medical Leave Own Serious Health Condition Packet | Complete this packet to apply for Delaware Paid Family and Medical Leave for your own serious health condition. |
Download |
| Dental Claim (All states except NY) | Use this form to report a treatment plan and to initiate a dental claim. |
Download |
| Dental Claim (NY) | Use this form to report a treatment plan and to initiate a dental claim. For use in New York only. |
Download |
| Dental Claim (Spanish - All states except NY) | Use this form to report a treatment plan and to initiate a dental claim (Spanish). |
Download |
| Dental Claim (Spanish - NY) | Use this form to report a treatment plan and to initiate a dental claim (Spanish). For use in New York only. |
Download |
| EFT for Dental & Vision Customers Based in NY | Use this Electronic Funds Transfer form to request and authorize a bank payment plan. For use in New York only. |
Download |
| EFT for Dental & Vision Customers Based Outside NY | Use this Electronic Funds Transfer form to request and authorize a bank payment plan. |
Download |
| EFT Setup for Long Term Disability Claim Payments (All states except NY) | Used to request the electronic funds transfer (EFT) of Long Term Disability claim payments. |
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| EFT Setup for Long Term Disability Claim Payments (NY) | Used to request the electronic funds transfer (EFT) of Long Term Disability claim payments. |
Download |
| Eye Med Vision Out of Network Claim | Used to initiate an out of network eye care claim. |
Download |
| Health Maintenance Screening Benefit Claim Form (All states except NY) | Use this form to file a Health Maintenance Screening claim by mail, email or fax. Or log in to file this claim online. |
Download |
| Health Maintenance Screening Benefit Claim Form (NY) | Use this form to file a Health Maintenance Screening claim in New York by mail, email or fax. Or log in to file this claim online. |
Download |
| Hospital Indemnity Benefit Claim Form (All states except NY) | Use this form to file a Hospital Indemnity insurance claim by mail, email or fax. Or log in to file this claim online. |
Download |
| Hospital Indemnity Benefit Claim Form (NY) | Use this form to file a Hospital Indemnity insurance claim in New York by mail, email or fax. Or log in to file this claim online. |
Download |
| Long Term Disability Claim Packet (All states except NY) | Use this packet to file a claim for a Long Term Disability plan issued outside of the state of New York. |
Download |
| Long Term Disability Claim Packet (NY) | Use this packet to file a claim for a Long Term Disability plan issued in the state of New York. |
Download |
| Massachusetts Paid Family and Medical Leave Bonding Leave Packet | Complete this packet to apply for Massachusetts Paid Family and Medical Leave to bond with a newborn, a newly adopted or fostered child. |
Download |
| Massachusetts Paid Family and Medical Leave Care of Family Member Packet | Complete this packet to apply for Massachusetts Paid Family and Medical Leave to care for a family member with a serious health condition. |
Download |
| Massachusetts Paid Family and Medical Leave Military Leave Packet | Complete this packet to apply for Massachusetts Paid Family and Medical Leave to assist family members due to another family member’s active military duty or impending active duty abroad. |
Download |
| Massachusetts Paid Family and Medical Leave Own Serious Health Condition Packet | Complete this packet to apply for Massachusetts Paid Family and Medical Leave for your own serious health condition. |
Download |
| Minnesota Paid Family and Medical Leave Bonding Packet | Complete this packet to apply for Minnesota Paid Family and Medical Leave to bond with a newborn, a newly adopted or fostered child. |
Download |
| Minnesota Paid Family and Medical Leave Care of Family Member Packet | Complete this packet to apply for Minnesota Paid Family and Medical Leave to care for a family member with a serious health condition. |
Download |
| Minnesota Paid Family and Medical Leave Military Leave Packet | Complete this packet to apply for Minnesota Paid Family and Medical Leave to assist family members due to another family member’s active military duty or impending active duty abroad. |
Download |
| Minnesota Paid Family and Medical Leave Own Serious Health Condition Packet | Complete this packet to apply for Minnesota Paid Family and Medical Leave for your own serious health condition. |
Download |
| New Jersey State Disability Claim Packet | Use this packet to file a claim through a New Jersey State Disability plan. |
Download |
| New York Paid Family Leave Bonding Leave Packet | Use this packet for file a claim for bonding leave under Paid Family Leave in New York. |
Download |
| New York Paid Family Leave Care of Family Member Packet | Use this packet for file a claim for care of family member leave under Paid Family Leave in New York. |
Download |
| New York Paid Family Leave Military Leave Packet | Use this packet for file a claim for military exigency leave under Paid Family Leave in New York. |
Download |
| New York State Disability Claim Packet | Use this packet to file a claim through a New York State Disability plan. |
Download |
| Oregon Paid Family and Medical Leave Bonding Packet | Complete this packet to apply for Oregon Paid Family and Medical Leave to bond with a newborn, a newly adopted or fostered child. |
Download |
| Oregon Paid Family and Medical Leave Care of Family Member Packet | Complete this packet to apply for Oregon Paid Family and Medical Leave to care for a family member with a serious health condition. |
Download |
| Oregon Paid Family and Medical Leave Own Serious Health Condition Packet | Complete this packet to apply for Oregon Paid Family and Medical Leave for your own serious health condition. |
Download |
| Pregnancy Dental Benefit Certification (All states except NY) | Authorize the release of medical information to The Standard for review for the Maternity Dental Benefit. |
Download |
| Pregnancy Dental Benefit Certification (NY only) | Authorize the release of medical information to The Standard for review for the Maternity Dental Benefit. For use in New York only. |
Download |
| Pregnancy Dental Benefit Certification (Spanish - All states except NY) | Authorize the release of medical information to The Standard for review for the Maternity Dental Benefit. (Spanish) |
Download |
| Pregnancy Dental Benefit Certification (Spanish - NY only) | Authorize the release of medical information to The Standard for review for the Maternity Dental Benefit. (Spanish) For use in New York only. |
Download |
| Short Term Disability Claim Packet (All states except NY) | Use this packet to file a claim for a Short Term Disability plan issued outside of the states of New York. |
Download |
| Short Term Disability Claim Packet (NY) | Use this packet to file a claim for a Short Term Disability plan issued in the state of New York. |
Download |
| Specified Disease Benefit Claim Form (NY) | Use this form to file a Specified Disease insurance claim in New York by mail, email or fax. Or log in to file this claim online. |
Download |
| Specified Disease Benefit Claim Form (VT) | Use this form to file a Specified Disease insurance claim in Vermont by mail, email or fax. Or log in to file this claim online. |
Download |
| Vision Claim Form (All states except NY) | Use this form to initiate a vision or PolicyLink claim. |
Download |
| Vision Claim Form (NY) | Use this form to initiate a vision or PolicyLink claim. For use in New York only. |
Download |
| Vision Claim Form (Spanish - All states except NY) | Use this form to initiate a vision or PolicyLink claim (Spanish). |
Download |
| Vision Claim Form (Spanish - NY) | Use this form to initiate a vision or PolicyLink claim (Spanish). For use in New York only. |
Download |
| VSP Vision Out of Network Claim | Used to request out of network eye care expense reimbursement. |
Download |
| Waiver of Premium Claim Packet (All states except NY) | If you have a life insurance policy issued outside of New York that includes the Waiver of Premium benefit, you can use this packet to request the waiver. |
Download |
| Waiver of Premium Claim Packet (NY) | If you have a life insurance policy issued in New York that includes the Waiver of Premium benefit, you can use this packet to request the waiver. |
Download |
| Washington Paid Family and Medical Leave Bonding Leave Packet | Complete this packet to apply for Washington Paid Family and Medical Leave to bond with a newborn, a newly adopted or fostered child. |
Download |
| Washington Paid Family and Medical Leave Care of Family Member Packet | Complete this packet to apply for Washington Paid Family and Medical Leave to care for a family member with a serious health condition. |
Download |
| Washington Paid Family and Medical Leave Military Leave Packet | Complete this packet to apply for Washington Paid Family and Medical Leave to assist family members due to another family member’s active military duty or impending active duty abroad. |
Download |
| Washington Paid Family and Medical Leave Own Serious Health Condition Packet | Complete this packet to apply for Washington Paid Family and Medical Leave for your own serious health condition. |
Download |