Documents

Medical Plan Documents

For plan information, click here.

Disability, Hospital or Surgical Benefits Claim Form
Disability Claim Form.pdf
Adobe Acrobat Document 759.0 KB

Return completed form to Fleet Owners Insurance Fund. Contact Us.

Claim Forms

Medical Claim Form
Medical Claim Form.ashx.pdf
Adobe Acrobat Document 56.3 KB
Dental Claim Form
Dental Claim Form.ashx.pdf
Adobe Acrobat Document 87.5 KB
Vision Claim Form
Vision Claim Form.ashx.pdf
Adobe Acrobat Document 76.0 KB
MMO Treatment Cost Estimator
You can get accurate estimates of your out-of-pocket costs through visiting Medmutual.com and signing into your Medical Mutual account. Check out the brochure for more information.
MMO Treatment Cost Estimator Instruction
Adobe Acrobat Document 1.4 MB
Prescription Claim Form
Rx Claim Paper Claim Form.pdf
Adobe Acrobat Document 147.8 KB

CVS Caremark/Medtipster.com Forms

Prescription Mail Order Form
CVS Caremark Mail Service.pdf
Adobe Acrobat Document 1.2 MB
Major Pharmacy Locations
Retail Pharmacies.pdf
Adobe Acrobat Document 655.4 KB
CVS Caremark Performance Drug List
July 2014 CVS Performance Drug List.pdf
Adobe Acrobat Document 371.3 KB
Formulary Drug Removals List
Formulary Drug Removals Jan 2014.pdf
Adobe Acrobat Document 998.9 KB
Prescription Drug Claim Form
Rx Claim Paper Claim Form.pdf
Adobe Acrobat Document 147.8 KB

Fleet Owners Insurance Fund Documents

Change in Status
Change in Status.pdf
Adobe Acrobat Document 205.8 KB
Notice of Privacy Policy
Notice of Privacy Practices.pdf
Adobe Acrobat Document 2.7 MB
Woman's Health and Cancer Rights Act of 1998
Women's Rights.pdf
Adobe Acrobat Document 308.7 KB
Medicare Notice
2014.02.19 Creditable Coverage MedicareP
Adobe Acrobat Document 104.4 KB
Life Insurance Application Plan A
Plan A Life Ins App 03 02 2015.pdf
Adobe Acrobat Document 71.9 KB
Life Insurance Application Plan B
Plan B Life Ins App 03 02 2015.pdf
Adobe Acrobat Document 71.9 KB