141 Broad Boulevard
PO Box 515
Cuyahoga Falls, Ohio 44222
Local - 330 923-3711
Toll Free - 1 800 247-3711
Claims Dept. Fax (330) 923-5765
Admin Fax (330) 923-1933
Site Navigation
Home Page
Our Management
Our Staff
Contact Information
Printable Forms
Claims Information
Member Claims
Provider Login
Employer Access
Provider 1099s
Section 125/FSA
Information
Participant Login
Employer Login
Other Products
Other Links
Ohio Department of
Insurnace
EBC Printable Forms
All forms on this page are made available in
Adobe Acrobat Portable Document Format
(PDF) If you do not have the
Adobe Acrobat Reader
installed on your computer, you may download and install it
FREE
from the
Adobe Download Site
.
Administration Kit Forms
Pages
PDF
Complete Administration Kit (One Document)
20
View/Print
Sales Kit Forms
Pages
Complete Sales Kit
13
View/Print
Authorization For Release of Medical Information
Pages
Generic Release Form
1
View/Print
Anthem Blue Cross Blue Shield
1
View/Print
John Alden (Assaunt Health)
1
View/Print
Medical Mutual Of Ohio
1
View/Print
Nationwide Insurance
1
View/Print
Nippon Life Insurance Company Of America
1
View/Print
Principal Life Insurance Company
1
View/Print
Starmark Insurance Company
1
View/Print
United Healthcare
1
View/Print
Miscellaneous Forms
Pages
Spousal Insurance Information
1
View/Print
Home
|
Our Management
|
Our Staff
|
Contact
|
Printable Forms
Site Design by Conring Automation Services
Akron, Ohio