Online Claim Form

Use this form when submitting a claim online! Your information will be transmitted securely. Your attachments will be purged from our servers once the claim has been submitted. Your information will NOT be stored in our online databases.
  • Please enter the name of your company
  • Please enter the name of the covered employee.
  • Please enter the date of the claim
    Date Format: MM slash DD slash YYYY
  • Please enter the employee's email
  • Please fill out the details of your claim. You can choose from: Dental; Prescription; Optometry; Massage; Chiropractic. You can total up each category and have 1 entry rather than multiple ones.
    Expense TypeExpense AmountReceipt Upload 
  • Any special requests or instructions.
  • This field is for validation purposes and should be left unchanged.