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download claim forms

When accessing or downloading online forms, you agree to release, indemnify and hold harmless Ameritas Life Insurance Corp. and/or its subsidiaries for any damage or liability encountered from using these forms. Please remember to keep only the most current Ameritas or Ameritas Life Insurance Corp. of New York forms on file.


Claim Forms
English Dental Claim Form (fillable PDF)
Spanish Dental Claim Form
Ameritas Vision Claim Form (fillable PDF) - for Vision Perfect plans, Dental plans with LASIK, Fusion plans and Dental plans with Exam Only benefit
Spanish Ameritas Vision Claim Form  (fillable PDF)
EyeMed Vision Out-of-Network Claim Form
VSP Vision Out-of-Network Claim Form
Total Vision Accidental Loss of Sight Claim Form
SoundCare Claim Form - for hearing care plans.
Individual Dental Claim Form - for individual plans
Individual Vision Claim Form - for individual plans (fillable PDF)

Claim Forms (NY)
English Dental Claim Form (NY) (fillable PDF)
Spanish Dental Claim Form (NY)
Ameritas of New York Vision Claim Form (NY) (fillable PDF) - for Vision Perfect plans, Dental plans with LASIK, Fusion plans and Dental plans with Exam Only benefit
Spanish Ameritas of New York Vision Claim Form (NY) (fillable PDF)
EyeMed Vision Out-of-Network Claim Form (NY)
VSP Vision Out-of-Network Claim Form (NY)
Total Vision Accidental Loss of Sight Claim Form (NY)
SoundCare Claim Form (NY) - for hearing care plans

 

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