Claim Forms

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Claim Forms

Use these forms to submit a health or dental claim

These forms are in PDF format and can be downloaded to and then printed from your computer with Adobe Acrobat Reader. If you do not have this free software installed on your computer, install it now. Once installed, it can be used to read many documents throughout the Web.

Select the name of the form you require and click to open it, print and complete.

Health Claim Forms
Health Claim Expense - Plan sponsor certified
Health Claim Expense - Direct claims submission
Health Claim Expense - Direct claims submission (Former Aetna Clients)

Dental Claim Forms
Dental Claim Expense - Plan sponsor certified
Dental Claim Expense - Direct claims submission
Dental Claim Expense-Direct claims submission (Former Aetna Clients)

Prior Authorization
Prior Authorization Form

Submit Your Form
Remember to sign the form and attach any necessary receipts. Then submit to your plan administrator, if that's who usually signs your forms. Otherwise, mail your form to the Maritime Life claims office at the address shown on the form.

If you have any questions regarding your claim, click here to contact a representative in our claims office.
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