Contact Us

Ask general questions, request an identification card, or contact us for a quote for your company. Select an appropriate online form below and submit it to us, or feel free to call us at 800-332-1168.

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Office Hours

Monday - Thursday: 7:30am to 4:30pm MST
Friday: 7:30am to 4:00pm MST

*Please note: The live chat feature is only available during office hours

Request a Quote

General Question

Member ID Card Request

Full Name: First, Last: (Required)
Employer: (Required)
Inquiry Type: (Required)
Member ID: (Required)
Phone:
Email: (Required)
Question:

Member Third Party Liability Information

Member Name: First, Last (Required)
Email (Required)
Member ID (Required)
Patient Name (Required)
Services Provided By (Required)
Date of Service:
Total Charge Amount:
Was Claim Due to Injury? (Required)

Yes

No
Injury/Illness Description:
First Date of Treatment: (Required)
Date of Injury: (Required)
How Did The Injury Happen: (Required)
Place of Injury: (Required)
Was Injury at Work: (Required)
Do You Expect Further Treatment: (Required)
Is This Causing Aggravation at Work: (Required)
Has Employer Been Notified: (Required)
Is Injury From Motor Vehicle Accident: (Required)
Was Vehicle Covered By Insurance: (Required)
Other Party Name:
Other Party Address:
Other Party Phone:
Claim Number:
Policy Number:
Was Accident Reported to Law Enforcement:
Name of Agency:
Agency Address:
Has Attorney Been Retained:
Home Phone:
Work Phone:
Electronic Signature: (Required)

Employer Supply Request

Group Name: (Required)

Branch Number: (Required)

Caller Name: (Required)

Email: (Required)

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Enrollment Packets Qty:

Medical Claim Forms Qty:

Dental Claim Forms Qty:

Vision Claim Forms Qty:

COBRA Forms Qty:

Rx Mail Order Forms Qty:

PPO Directories Qty:

SDA LDT/SDT Claim Forms Qty:

SDA LDT/SDT Certs Qty:

Standard Voluntary Life Booklets:

Other:

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