Whether you need to submit a claim form depends on the plan you have selected and the type of service you are requesting for reimbursement. The following is a list of services that in some cases require you to complete a claim form.

PPO Medical Plan
Submit a medical claim form along with an itemized bill to United Medical Resources, Inc. (UMR) (formerly Fiserv Health Plan Administrators) if the provider of service does not bill insurance. Get a copy of the Medical Claim Form [.PDF].

PPO Dental Plan
(includes participants of the PPO medical plan as well as members of an HMO medical plan). Submit a dental claim form along with an itemized bill to United Medical Resources, Inc. (UMR) (formerly Fiserv Health Plan Administrators) if the provider of service does not bill insurance. Get a copy of the Dental Claim Form [.PDF].

PPO Vision Plan
Submit a claim form along with an itemized bill to United Medical Resources, Inc. (UMR) (formerly Fiserv Health Plan Administrators). Get a copy of the Medical/Vision Claim Form [.PDF].

PPO Prescription Drug Plan
If you do not use your PPO plan ID card or you use an out of network pharmacy, please complete a direct member reimbursement form. Get a copy of the Prescription Direct Reimbursement Form [.PDF].

Life Claim
To submit a proof of death claim please contact the Public Employee’s Benefits Program (PEBP) Member Service’s at 775-684-7000 or 800-326-5496. PEBP’s Member Services will assist you with filing a proof of death claim with Standard Insurance.

Long-Term Disability
To submit a Long Term Disability claim, please contact Standard Insurance.

Voluntary Short-Term Disability Claim
Please contact Colonial Supplemental Insurance.

Click here if your Voluntary Short-Term Disability is with The Standard.

Voluntary Long-Term Care Insurance
Please contact UnumProvident Corporation. Select “Service Forms”.

Flexible Spending Account
Please contact ASI.

Voluntary Homeowners, Auto and Rental Insurance.
Please contact Liberty Mutual.