Claim forms

Most vision providers will submit claims on your behalf, but if you need to submit a claim yourself, please use the claim form linked below. Please check with your provider to verify if you need to submit a claim.

Submitting a claim

To submit a claim, download the form linked below, complete it and return it to us along with a detailed receipt from your dentist. You can send it by any of the options below.

  • Email here
  • Fax to 855-400-9307, or
  • Mail to:
    Claims Department
    P.O. Box 80139
    Baton Rouge, LA 70898-0193

Other vision forms:

Grievance Form — Request for review and reconsideration of a submitted claim.

AZ Health Coverage Appeal Information Packet — Important information for our members in Arizona about how to appeal decisions Starmount Life Insurance Company makes about your health coverage.

Hearing Savings Plan Flyer — Learn how you can access savings on hearing instruments and accessories.

For additional forms and documents, visit your member website.