Claim Forms

Step 1: Fill out a claim for yourself

Submit a Claim Yourself

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: If you have one of these plans, please use the correct form.

Accident Expense Plan

Download a PDF file of the InsuranceTPA Claim Form

Deductible Supplement Plan

Choose an option below:

QHP Supplemental Plan

Download a PDF file of the InsuranceTPA Claim Form

Step 3: Make a copy for your records and mail to the following address.

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

If you have claims questions about a submitted claim, your eligibility or your benefits, please call (800)-279-2290 or 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.
Claims Department