Health Insurance Assistance Claim Form Request

The Health Insurance Assistance claim form can only be requested, not printed, from this site.

* 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?*
Please give us 24-hr notice
* These Fields Must be Filled in for your Request to be Processed
SUBMIT ONLY ONE FORM PER FAMILY