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Health Insurance Assistance Claim Form Request
The Health Insurance Assistance claim form can only be requested, not printed, from this site.
This is for the 2021 Health Insurance Assistance claim form only. You may request the 2022 claim form after June 1st.
* These Fields Must be Filled in for your Request to be Processed
Please provide the following information:
Member Information
Member ID (BF#)*
Member's Last Name*
Member's First Name*
Middle Initial
Date of Birth*
(format: MM-DD-YYYY)
Mailing Address*
City*
State*
Zip Code*
Member's E-mail*
Day Telephone*
Would you like to pick up the form?*
Yes
No
Please give us 24-hr notice
* These Fields Must be Filled in for your Request to be Processed
SUBMIT ONLY ONE FORM PER FAMILY
Enter the characters above