High Option Plan

Claim Forms

Member Medical Claim Form - Complete this claim form to submit your covered medical expenses to the Plan. If you currently have Medicare coverage or are submitting a foreign claim, please mail a completed claim form to the following address: 

NALC Health Benefit Plan
20547 Waverly Court
Ashburn, VA 20149

Form 41 - Complete this questionnaire in full when you or a covered family member have: 1) coverage under any other health plan 2) automobile insurance that pays health care expenses without regard to fault 3) Medicare coverage, or 4) a workplace-related illness or injury.

Form J400 - Complete this claim form to submit your covered dental accident expenses to the Plan.