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The following is a claim service form to be completed in the event you are having problems getting your claim resolved.  Or call us at 707-792-8080.
 
Group Name:  
Employee :  
Patient Name:  
Emp. Date of Hire:  
Emp. phone:  
Date of Service:  

Name of Provider:  


Phone # of Provider:  

Employee Effective Date with Insurance:  
Amount of Bill & Amount Paid by Insurance:  
Amount Owed by Employee:  
Additional Information that might help expedite the claim process:
By clicking submit, I understand this is not an actual claim, but notifying my agent to help my agent with the process of my claim.