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IRS Form 1095-B Appeals and Grievance Medical and Prescription Drug Request form California plan continuity of care forms Certificate of Coverage (COC) or Proof of Lost Coverage (POLC) Form Community plan release of information forms Dental forms Disability, life and supplemental insurance claim forms Flexible Spending Account (FSA), Health Reimbursement Account (HRA), and Health Savings Account (HSA) forms Medical reimbursement forms Oxford health plan forms Power of attorney forms UnitedHealthcare SignatureValue® managed care forms Share Disclaimers for Disability, life and supplemental insurance claim forms Note about email: We cannot guarantee the security of any communication transmitted through the internet. We are not liable for the illegal acts of third parties such as criminal hackers. Please use your best judgment when deciding how to email your information. We can accept emails sent with or without encryption. UnitedHealthcare Life and Disability products are provided by UnitedHealthcare Insurance Company and certain products in California by Unimerica Life Insurance Company. Life and Disability products are provided on policy forms LASD-POL (05/03) et al. and UHCLD-POL 2/2008 et al., in Texas on forms LASD-POL-TX(05/03) and UHCLD-POL 2/2008-TX and in Virginia on LASD-POL(05/03) and UHCLD-POL 2/2008. The policies have exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company. Some products are not available in all states. UnitedHealthcare Insurance Company is located in Hartford, CT and Unimerica Life Insurance Company is located in Milwaukee, WI. UnitedHealthcare Critical Illness product is provided by UnitedHealthcare Insurance Company on form UHICI-POL-1 et al., in Texas on UHICI-POL-1 and in Virginia on UHICI-POL-1-VA. Critical Illness coverage is NOT considered "minimum essential coverage" under the Affordable Care Act and therefore does NOT satisfy the mandate to have health insurance coverage. Failure to have other health insurance coverage may be subject to a tax penalty. Please consult a tax advisor. The policies have exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company. Some products are not available in all states. UnitedHealthcare Insurance Company is located in Hartford, CT. UnitedHealthcare Accident Protection product is provided by UnitedHealthcare Insurance Company on form UHCAC-POL-1 (01/12) et al., in Texas on form UHCAC-POL-1-TX (01/12) and in Virginia on UHCAC-POL-1-VA (01/12). The policies have exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company. Some products are not available in all states. UnitedHealthcare Insurance Company is located in Hartford, CT. UnitedHealthcare Hospital Indemnity product is provided by UnitedHealthcare Insurance Company on policy forms UHIHIP-POL-TX, et al. and UHIHIP-CERT-TX, et al. in Texas and UHIHIP-POL-VA, et al. and UHIHIP-CERT-VA, et al. in Virginia. The product provides a limited benefit for certain hospital indemnity plan benefits. Please note: HOSPITAL INDEMNITY coverage is NOT considered "minimum essential coverage" under the Affordable Care Act and therefore does NOT satisfy the mandate to have health insurance coverage. Failure to have other health insurance coverage may be subject to a tax penalty. Please consult a tax advisor. The policy has exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company. This product is not available in all states. UnitedHealthcare Insurance Company is located in Hartford, CT. Life and Disability products are provided by Unimerica Life Insurance Company of New York. Life and Disability products are provided on policy forms LASD-POL-LIFE NY (05/03) and LASD-POL-ADD/DIS NY (05/03). This policy includes exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company. Unimerica Life Insurance Company of New York is located in New York, NY. Specified Disease insurance is provided by Unimerica Life Insurance Company of New York on form UHICI-POL-1-NY. Specified Disease coverage is NOT considered "minimum essential coverage" under the Affordable Care Act and therefore does NOT satisfy the mandate to have health insurance coverage. Failure to have other health insurance coverage may be subject to a tax penalty. Please consult a tax advisor. This policy has exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company. Unimerica Life Insurance Company of New York is located in New York, NY. Accident Protection product is provided by Unimerica Life Insurance Company of New York on form UHCAC-POL-1-NY (01/12). This policy has exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company. Unimerica Life Insurance Company of New York is located in New York, NY. Hospital Indemnity Protection Plan is provided by Unimerica Life Insurance Company of New York on policy form UHIHIP-POL-NY. The product provides a limited benefit for certain hospital indemnity plan benefits. Please note: HOSPITAL INDEMNITY coverage is NOT considered "minimum essential coverage" under the Affordable Care Act and therefore does NOT satisfy the mandate to have health insurance coverage. Failure to have other health insurance coverage may be subject to a tax penalty. Please consult a tax advisor. The policy has exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company. Unimerica Life Insurance Company of New York is located in New York, NY. 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