Member Reimbursement Claim

Reimbursement Claim Form

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Policyholder/Named Participant Information

Policyholder/Named Participant Name(required)

First Last

Mailing Address(required)

Street Address City State

ZIP Code

Policyholder/Named Participant Email(required)

Phone Number(required)

Subscriber ID Number(required)

This 9 digit Subscriber ID number can be found on your member ID card.

Please select the Policyholder/Name Participants relationship to the member who receive the legal service in which reimbursement is being sought for?(required)

Self- Policyholder/Named Participant

Spouse

Joint Matter - Policyholder/Named Participant and Spouse

Spouse Name(required)

First Last

Dependent Child Name(required)

First Last

Spouse Date of Birth(required)

Dependent Child Date of Birth(required)

Select the Plan you are enrolled in(required)

Independent Secure Plan

Group Preferred Plan

Group Select Plan

Benefits

Select the benefit that applies to the legal service reimbursement is being sought.

Secure/Preferred Plan(required)

Select Plan(required)

Adoption(required)

Uncontested Adoption 39301 - Up to $500

Contested Adoption 39302 - Up to $1,000

Annual Accounting of Guardianship(required)

Annual Accounting of Guardianship 39101- Up to 6 hours ($50/hour)

Bankruptcy(required)

Chapter 7 19501 - Up to $500

Chapter 13 19502 - Up to $700

Consultation(required)

Consultation 18309 - $50 per Consult

Consumer Protection(required)

Negotiations with Demand Letter 24391 - Up to $300

Representation without Trial 24392 - Up to $600

Representation with Trial 24393 - Up to $1,500

Consumer Protection(required)

Negotiations with Demand Letter 24394 - Up to $300

Deeds(required)

Deeds 71409 - Up to 2 hours ($50/hour)

Defense of Civil Action(required)

Defense of Civil Action 16209 - Up to 20 hours ($50/hour)

Defense of Civil Action(required)

Defense of Civil Action 16309 - Up to 10 hours ($50/hour)

Driving Privileges(required)

License Suspension/Revocation 93209 - Up to $600

Administrative License Revocation Hearing 93903 - Up to $300

Driving/Boating While Intoxicated(required)

DWI/BWI 80309 - Up to $800

Elder Law(required)

Elder Law 49101 - Up to 4 hours ($50/hour)

Elder Law(required)

Elder Law 49102 - Up to 2 hours ($50/hour)

Estate Planning(required)

Select all that apply.

Codicil 29301 - $75(Individual) or $100(Joint)

Will(s) & Testamentary Trust(s) 29302 - $200

Will(s) & Living Trust(s) 29303 - Up to 8 hours ($50/hour)

Power(s) of Attorney 29304 - Up to 2 POA's(Individual) or Up to 4 POA's(Joint) $50 per document

Living Will(s)/Advance Directive(s) 29305 - $25(Individual) or $50(Joint)

Declaration of Guardianship 29306 - $25(Individual) or $50(Joint)

Disposition of Remains 29307- $25(Individual) or $50(Joint)

HIPPA Release 29308- $25(Individual) or $50(Joint)

Expunction/Order of Nondisclosure(required)

Expunction/Order of Nondisclosure 49301 - $400

Family Law(required)

Divorce Uncontested 21909- Up to 15 hours ($50/hour)

Divorce without children Contested 21902 - Up to 15 hours ($50/hour)

Divorce with children Contested 21903 - Up to 30 hours ($50/hour)

Modification/Enforcement/Establishment Uncontested 15409 - Up to 15 hours ($50/hour)

Modification/Enforcement/Establishment Contested 15902 - Up to 20 hours ($50/hour)

Family Law(required)

Divorce 21904 - Up to 15 hours ($50/hour)

Modification/Enforcement/Establishment Contested 15903 - Up to 15 hours ($50/hour)

Felony(required)

Felony Without Trial 75901 - $1,000

Felony With Trial 75902 - $2,000

Gender Identifier Change(required)

Gender Identifier Change 62901 - $200

General Legal Services(required)

General Legal Services 17309 - Up to 6 hours ($50/hour)

General Legal Services(required)

General Legal Services 17392 - Up to 4 hours ($50/hour)

Guardianship or Conservatorship(required)

Guardianship or Conservatorship Uncontested 37901 - $400

Guardianship or Conservatorship Contested 37902 - Up to 15 hours ($50/hour)

Habeas Corpus(required)

Habeas Corpus 60309 - $200

Immigration Assistance(required)

Immigration Assistance 81901 - Up to 6 hours ($50/hour)

Incompetency or Infirmity(required)

Incompetency or Infirmity 43209 - $800

Juvenile Court(required)

Juvenile Court 50509- $800

Misdemeanor(required)

Misdemeanor 16901 - $800

Name Change(required)

Name Change 41291 - $200

Prenuptial or Postnuptial Agreement(required)

Prenuptial or Postnuptial Agreement 65901 - $300

Probate(required)

Probate With a Will Uncontested 52391 - Up to 15 hours ($50/hour)

Probate With a Will Contested 52392 - Up to 15 hours ($50/hour)

Probate Without a Will Uncontested 52393 - Up to 15 hours ($50/hour)

Probate Without a Will Contested 52394- Up to 15 hours ($50/hour)

Property Tax- Primary Residence(required)

Property Tax- Primary Residence 78901 - $200

Protective Order(required)

Protective Order 37209 - $200

Public Intoxication(required)

Public Intoxication 82309 - $200

Residential Real Estate Transaction(required)

Residential Real Estate Transaction 36291 - $200

School Administrative Hearings(required)

School Administrative Hearings 87891 - Up to 4 hours ($50/hour)

Social Security/Veterans/Medicare(required)

Social Security/Veterans/Medicare 48901 - Up to 4 hours ($50/hour)

Social Security/Veterans/Medicare(required)

Social Security/Veterans/Medicare 48902 - Up to 2 hours ($50/hour)

Tax Audit(required)

Tax Audit 17691 - Up to 4 hours ($50/hour)

Traffic Ticket(required)

Traffic Ticket 38791- $150

Required Documents

All documents listed below ARE required for claim processing.

Adoption(required)

*Missing any of the documents listed below will result in claim denial.

1st Page of Original Petition for Adoption with File Date Stamp

Order Granting Adoption with File Date Stamp