Non-Bar Coded Claim Forms
img Best Option: As a better alternative to the claim forms listed below, we offer a private, secure online claims entry application (requires login with your MyEnroll.com User ID and Password).

From this application, you can upload images of your claims receipts (requires scanning your claims into your computer) or printing out your claim form with all the necessary information for use in faxing or mailing to us. For the online application click here...

Option 1: HTML Online Fill-in Format

Fill in online and save to computer. This does not make an online submission, but merely a form for typing your information and saving to your computer.

Option 2: Adobe Acrobat PDF

PDF is a de facto standard for making documents transportable among computers. The free Adobe Acrobat Reader must be installed on your computer to use this option.

Option 3: Microsoft Word Format

Microsoft Word is the leading word processor and is installed on a large majority of computers. If you have MS Word installed, you may use this option.