GAP CLAIM FORMS.

Below are the claim forms for the Critical Illness and Accident Medical Expense Benefits.

 

Critical Illness Claim Form (All GAP Plans use this same claim form)

Accident Claim Form:

• GAP Plus Plan^SM & GAP 10K Plus Plan^SM Claim Form

• GAP 10K² Plan^SM Claim Form

 

*For full details, limitations, exclusions, age limits, state availability, and definitions, please refer to the member benefit guide. This is not an individual major medical health plan. This plan was designed to coordinate with a major medical high deductible plan. The Accident and Critical Illness benefits are not available in the GAP Basic Plan^SM. The Accident Benefit is not available with the GAP CI Plan^SM. Check plans for benefits offered in each plan.