UCEAP Insurance Claim Form
READ FIRST:
• Complete this form in its entirety. All relevant fields are required to process the
claim promptly.
• If we require additional information or documentation, we will mail a request to
the address on file and you will be contacted by email.
• Claim Form must be completed and returned with itemized bills within 90 days.
• After completing this form, you can save/print a PDF copy for your records
and upload documentation to support the reimbursement claim.
[.doc, .docx, .pdf, .xls, .xlsx, .txt, .jpg, .tif, .png, .gif]
Personal Information
Insured First Name Middle Initial Last Name
Date of Birth Member ID (UC Campus ID)
/ /  mm/dd/yyyy
If this claim is for the spouse or child of the insured:
Full Name of Dependent Age Relationship to Insured
Address Information
• We will issue a check in US dollars for eligible reimbursements.
• Provide the mailing address where we should mail the check.
   Please check this box if the address is not in the United States.
Street Address
Additional Address Information
City
State Zip Code
City
Country Postal Code
Phone
Email
Claim Information
Is the claim related to an Accident or a Sickness/Pregnancy?
If you are filing this claim as a representative of the insured, please provide the following information:
Full Name of Representative
Relationship to Claimant
   
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