Need a form or claim information? You’ll find everything you need here.
Stop Loss Insurance
To submit a Specific Stop Loss claim:
- Complete the 50% notice or reimbursement request below, depending on the claim status.
- Submit the completed form to the address shown on the form, along with any required documentation.
To submit an Aggregate Stop Loss claim:
- Complete the Aggregate monthly report below.
- Submit the completed form to the address shown on the form, along with any required documentation.
IMPORTANT: Be sure to select the correct form. If your policy number starts with EMC L or ERL L, please choose Berkley Life and Health Insurance Company. If your policy number starts with ERC V or ERL V, please choose StarNet Insurance Company.
| Forms - Berkley Life and Health Insurance Company | Last Revised |
|---|---|
| Stop Loss 50% Notice | 11/24 |
| Stop Loss Reimbursement Request | 11/24 |
| Aggregate Monthly Report/Reimbursement Request | 11/24 |
| Monthly Aggregate Claim Checklist | 5/23 |
| Year-End Aggregate Claim Checklist | 5/23 |
| Continuing Eligibility Questionnaire | 11/24 |
| Forms - StarNet Insurance Company | Last Revised |
| Stop Loss 50% Notice - StarNet | 11/24 |
| Stop Loss Reimbursement Request - StarNet | 11/24 |
| Aggregate Monthly Report/Reimbursement Request - StarNet | 11/24 |
| Continuing Eligibility Questionnaire - StarNet | 11/24 |
Questions?
Please contact Amy Hartigan, Asst. VP of Claims at (609) 584-4602 or [email protected]
Accident Insurance
To submit an accident claim:
- Your employer, group, or association will provide you with a claim form for your coverage.
- Submit the completed form to the address shown on the form, along with any required documentation.
Electronic Funds Transfer
To have reimbursements or payments deposited directly into your bank account:
- Complete the Automated Clearing House (ACH) form below.
- Submit the completed form to the address shown on the form, along with any required documentation.
If you want deposits made to an account other than a checking account, please send an approval letter from your bank, instead of a voided check.
| Form - Broker Commission ACH | Last Revised |
|---|---|
| Broker Commissions ACH Authorization | 7/24 |
IMPORTANT: Be sure to select the correct Stop Loss form. If your policy number starts with EMC L or ERL L, please choose Berkley Life and Health Insurance Company. If your policy number starts with ERC V or ERL V, please choose StarNet Insurance Company.
| Form - Stop Loss Claims ACH | Last Revised |
|---|---|
| Stop Loss Claims ACH Authorization - Berkley Life and Health Insurance Company | 11/24 |
| Stop Loss Claims ACH Authorization - StarNet Insurance Company | 11/24 |
IMPORTANT: Be sure to select the correct Managed Care form. If your policy number starts with PXL L or HMR L, please choose Berkley Life and Health Insurance Company. If your policy number starts with PXL V or HMR V, please choose StarNet Insurance Company.
| Form - Managed Care Claims ACH | Last Revised |
|---|---|
| Managed Care Claims ACH Authorization - Berkley Life and Health Insurance Company | 11/24 |
| Managed Care Claims ACH Authorization - StarNet Insurance Company | 11/24 |
Berkley Edge Cost-Containment Solutions
To request services from Berkley Edge:
- Complete the referral form below.
- Submit the completed form to the address shown on the form, along with any required documentation.
| Form | Last Revised |
|---|---|
| Berkley Edge Referral | 5/21 |
Third Party Administrators
To work with us as a Third Party Administrator (TPA):
- Complete the TPA Questionnaire below.
- Submit the completed form to your Berkley Accident and Health representative, along with any required documentation.
| Form | Last Revised |
|---|---|
| TPA Appointment Questionnaire | 07/15 |