• 
• 
  • Providers Home
  • Member Eligibility and Benefits
  • Claim Information
    • Claim Status
    • Claim Action Request
  • Prior Authorization
  • Provider Administrative Resources
    • Provider Information
    • Provider Administration Manual
    • Claim Action Request
    • Quick Reference
  • Clinical Resources
  • Contact Information
• 
  • Agents Home
  • Contact Information
• 
  • Employers Home
  • Self Service
  • Contact Information
  • EAP
• 
  • Members Home
  • Self Service
  • Care Management
  • Contact Information
  • EAP
  • 24-Hour Nurse Line
• 
  • About Us
• 

Forms

The following downloadable forms are available for your convenience. If you have questions or need assistance, please contact us at 614-310-0555 or 1-866-929-8722.

Appointment Documentation Appointment Process Instructions Agent/Agency Application for Appointment Agent/Agency Agreement Agent List Appendix A Commissions EFT Commission Authorization W-9 Form Application & New Group Forms Electronic Funds Transfer Authorization Employee Application 100+ Employees Employee Application Under 100 Employees Enrollment Consent Agreement Group Market Employer Application Sold Case Checklist Marketing Materials TPAC Difference Brochure WellPAC

©Copyright 2008 | The Physicians' Assurance Corp | 1.614.310.0555