Accident/Emergency Information

 Envelope of Life/ Emergency Medical Information (820k)
What is an EMI? An EMI or Emergency Medical Information is a form that provides valuable information in a quick glance to medical personnel that need to take care of you. You can also call The Health Plan at 1.800.624.6961, Ext. 7659 or 740.695.7659 for a copy of the EMI form

 Accident Report (253k)
This form is to be filled out if Health Contract contains a subrogation clause. The Health Plan is obligated to recover any claim payments made on your behalf from the third party's insurance carrier or from you if you received that claim payment. Contact our Funds Recovery Department at 1.800.624.6961, ext. 7903 if you have any questions, or to give the information by phone.

Users with the most recent version of Adobe Acrobat or Adobe Reader (7.0 or greater) can fill out the form ONLINE and click "Print Form" when finished and mail or fax to the appropriate department.