Claim Forms

 

Step 1: Fill Out a Claim for Yourself

Smart Accident Plus & Gap Assurance Plan Customers use the Form below, all others, use the forms on the right.

Please have your provider complete an HCFA–1500 form (non-hospital claims) for services you’ve paid for up front.

If the provider is unable to fill out the claim form, please follow the instructions below.
(use downloadable form below and make copies as needed)

Accident Expense Plan

Download a PDF file of the InsuranceTPA Claim Form

Download a PDF file of the InsuranceTPA Claim Form

Instructions on how to fill out the Health Claim Form

View an example of a filled out Health Care Claim Form.

Smart Accident Plus & Gap Assurance Plan Customers use the Form below, all others, use the forms on the right.

Accident Expense Plan

Download a PDF file of the InsuranceTPA Claim Form

Please have your provider complete an HCFA–1500 form (non-hospital claims) for services you’ve paid for up front.

If the provider is unable to fill out the claim form, please follow the instructions below.
(use downloadable form below and make copies as needed)

Download a PDF file of the InsuranceTPA Claim Form

Instructions on how to fill out the Health Claim Form

View an example of a filled out Health Care Claim Form.

Step 2: File Your Claim

Make a copy for your records and mail to the following address.

InsuranceTPA.com
CLAIMS DEPARTMENT
14 N. Parker Drive
Janesville  WI 53545

Or Use the Customer Document Uploader on the Current Members Page.

If you have claims questions about a submitted claim, your eligibility or your benefits,

please call the number on the back of your ID card or email claims@insurancetpa.com.

The hours of operation at InsuranceTPA.com, Inc Customer Service are 8:30 am – 5:00 pm CT Monday-Friday.

Thank you!

InsuranceTPA.com, Inc.