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Supplemental Health Claim Form
File an accidental injury, critical illness, hospital care, or wellness claim.
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]
- Physician Statement [PDF]
Note: Based on higher than normal claim volumes, please allow additional time for review.
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The Cigna Group Information
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 Healthcare representative.
All Cigna Healthcare products and services are provided exclusively by or through operating subsidiaries of The Cigna Group 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 The Cigna Group 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 Healthcare name, logo, and other Cigna Healthcare marks are owned by Cigna Intellectual Property, Inc. LINA and NYLGICNY are not affiliates of The Cigna Group.