EUTF Claim Form
Plan Year: July 1, 2019 to June 30, 2020.
The filing deadline for dates of service between July 1, 2018 and June 30, 2019 is October 28, 2019 or 120 days after your termination date, whichever is earlier. The plan will not pay any claims received after the filing deadline.
Please follow the Claim Filing Requirements. Complete the information below for medical care and/or prescription drug expenses that were incurred by you or your eligible dependents. The services must have been paid by your primary health insurance plan to be eligible for reimbursement. Failure to complete the required information on this form or follow the Claim Filing Requirements will result in a delay in processing your claim.