Claim Forms

Below are claim forms for various plans.  
*****Please check your plan number before choosing a claim form. Sending your claim to the wrong company or using the wrong form results in delays or a denied claim. 
If you are unsure which form to use, please contact your agent as listed on your ID card or 888-301-9289 or

If the claim address on your plan is: 

GBG Administrative Services
26741 Portola Pkwy Suite 1E #527
Foothill Ranch CA 92610
Or Email:

Use these forms:

If the claim address on your plan is: 
Attention: Co-ordinated Benefit Plans, LLC
On Behalf of Nationwide Mutual Insurance Company and Affiliated Companies
P.O. Box 26222
Tampa, FL  33623

If you need help finding or submitting a claim form please use the "Chat Now" feature below to chat with a representative.