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SecureOne Benefit Administrators, Inc.
800-876-7475
Forms, SecureOne Benefit Administrators
Self-Funded Forms
  • Self-Funded COVID-19 Testing Reimbursement Form
  • Claim Form - Disability
  • Self-Funded Group Enrollment Form
Preferred United Plans "Alternative Funding" Forms
  • PUP COVID-19 Testing Reimbursement Form
  Michigan and Kentucky
  • ​Request for Proposal 
  • Employer Application 
  • Employee Health Questionnaire​​ 
Benefit Summaries (MI & KY)
  • PPO – 100%, 90%, 80% or 70%
  • HSA – 100% or 80%​
  Ohio
  • Request for Proposal 
  • Employer Application 
  • Employee Health Questionnaire 
Benefit Summaries (OH)
  • PPO – 100%, 90%, 80% or 70%
  • HSA – 100% or 80%
Flexible Spending Forms
  • Flexible Spending Claim Form
Administrators With a Solution
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