Agency Forms

Employee Forms Procedure

Employee Enrollment Form

Employee Change Form

Employee Termination Form

Employee Declination of Coverage Form

OneAmerica Life Insurance Beneficiary Form


Member Forms

III-A Claims Form

III-A Claims Form – Specialty Programs

ProAct Direct Member Reimbursement Form

Inpatient Behavioral Health Program Form

BCI Member Claim Form

Coordination of Benefits Form 

Disabled Member Form


EAP Provider Form

III-A EAP Claim Form

Vendor Payment Form


Acupuncture Provider Form

Acupuncture Claim Form
When submitting a form to the III-A that has personal information, please request a secure email from [email protected] or fax to 208-575-6423.  Must have Adobe Reader.