Stop Loss Concepts - Managing Underwriters and Program Administrators

Online Forms

Click on a form below to complete it online and submit it electronically.

Initial Large Claim Referral/50% Notification
Specific Reimbursement
Aggregate Reimbursement
Managed Care Evaluation

For help completing any of our online or standard forms, please call our office toll-free at: (800) 795-6709

Standard Forms

These are plain PDF versions of our online forms. They can be downloaded, by clicking on the link below, printed and faxed or mailed back to our office.

Standard Stop Loss Disclosure Form
Specific Reimbursement Form
Aggregate Reimbursement Form
Managed Care Evaluation Form

Forms can be faxed to us at:
(315) 449-1921