Verification of Dependent Eligibility

The completed form can be faxed to (406) 523-3187 or toll-free to 1-800-257-0950, or mailed to:

Please do not hesitate to contact us if you have any questions. Our Enrollment Department Team may be reached at 1-800-877-1122.

By submitting this information you are stating that the information, to the best of your knowledge, is correct.