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Home Individuals & Families Member GuideSupplemental Health Claim Form

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How to submit a claim

First, you will need to fill out the claim form below. A few key things to remember:

  • Please provide as much information as possible.
  • All fields are required unless marked optional.
  • A claim cannot be submitted without the required fields completed.
  • Click the “Next” button at the bottom of each page to save your information.
  • In the last step, you’ll be able to review and print all the information you’ve provided.

If at any time you have questions or need assistance, please call .

You may also submit your claim by fax, email, or mail by downloading, printing, and completing one of these claim forms:

  • Accidental Injury [PDF]
  • Critical Illness [PDF]
  • Hospital Care [PDF]
  • Wellness Incentive [PDF]

Note: Based on higher than normal claim volumes, please allow additional time for review.

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Product availability may vary by location and plan type and is subject to change. All health insurance policies and health benefit plans contain exclusions and limitations. For costs and details of coverage, review your plan documents or contact a Cigna representative.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna HealthCare of Arizona, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of North Carolina, Inc. and Cigna HealthCare of Texas, Inc. Group health insurance and health benefit plans are insured or administered by CHLIC, Connecticut General Life Insurance Company (CGLIC), or their affiliates ( see a listing of the legal entities that insure or administer group HMO, dental HMO, and other products or services in your state). Accidental Injury, Critical Illness, and Hospital Care plans or insurance policies are distributed exclusively by or through operating subsidiaries of Cigna Corporation, are administered by Cigna Health and Life Insurance Company, and are insured by either (i) Cigna Health and Life Insurance Company (Bloomfield, CT); (ii) Life Insurance Company of North America (“LINA”) (Philadelphia, PA); or (iii) New York Life Group Insurance Company of NY (“NYLGICNY”) (New York, NY), formerly known as Cigna Life Insurance Company of New York. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. LINA and NYLGICNY are not affiliates of Cigna.

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