Claims & Insurance Forms

The list below contains forms available for download for current AMA Insurance certificate holders. If you have any questions about these forms, or would like AMA Insurance to mail you a form instead, please contact us.

Please note that some of the forms below allow you to type information directly into the PDF, however, for privacy purposes, you may not save a filled out form.

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Beneficiary Change Request Form
Request for Identifying Information Form
(NOTE: This is NOT a Change of Beneficiary Form)
Transfer of Ownership (Absolute Assignment) Forms
Transfer of Ownership and Beneficiary Designation Form
Collateral Assignment Forms
Collateral Assignment Form (DI/OOE Plans)
Collateral Assignment Form (Life Plans)
Collateral Assignment Form (AD&D Plans)
Release of Collateral Assignment Form

Dental Insurance
Dental Insurance Claim Form
File a claim for dental services.
Hospital Income (Hospital Indemnity) Insurance Plan
Hospital Income (Hospital Indemnity) Insurance Form
In order to file a claim, complete, date, sign and return this form with one of the following: 1) A UB-04 form issued by the hospital. 2) An itemized hospital bill, along with a diagnosis provided by your attending physician. A balance due statement is not acceptable. 3) A statement from the hospital indicated the admission date, discharge date, number of days, type of room and diagnosis.
Catastrophic Major Medical/Excess Major Medical Insurance
Catastrophic Major Medical Claim Form
File a claim for Catastrophic Major Medical insurance.
For All Other Claims

Please contact Customer Care at 800.458.5736 (8 am – 5 pm CT, Monday – Friday).
Medicare Supplement Claim Appeal Procedures
Arizona Grievance Procedures
Kentucky Appeals Procedures
Hospital Income (Hospital Indemnity) Insurance Plan
Hospital Income (Hospital Indemnity)
Add dependent(s) to your coverage.

Electronic Fund Transfer (EFT) Enrollment Form: Set up automatic monthly payments from your bank account.

Add Secondary Address
Add Secondary Addressee Form
Add another address/individual to your account. They will receive a copy of billing and lapse notices to help prevent unintentional lapse of insurance coverage.
Catastrophic Major Medical Insurance Hospital Directory

 

View the directory of hospitals in the CMM plan. Admittance to a network hospital is recommended but not required by this plan.

SMRU #1766472

Questions?

800.458.5736

Contact Customer Care
8am – 5pm (M-F, CT)
or Contact Us online.

wecare@amainsure.com