Request a cafeteria claim form

Please provide the following information. A form will be sent to you in 1-3 days. If there are any problems with your request, a representative of Wagstaff & Crawford will contact you.

You may also obtain a claim form from your Human Resources department or by calling WC Administrators at 1-800-748-4865 or (801)595-1100.

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Please note: WC Administrators can only process an cafeteria claim for participants in a plan that we currently administer. Your company's Human Resources department can give you information about who administers your cafeteria plan and how to make a claim.

I am a participant in a plan administered by WC Administrators.

I am not a participant in a plan administered by WC Administrators.

I don't know if WC Administrators is my plan administrator.

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Participant Information

*First Name:       *Last Name: 

*Company Name:

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*Type of claim form:

  Medical Reimbursement
  Dependent Day Care
  Vacation Savings

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Contact / Delivery Information

Mailing Address

Street:  

City:      

State:   Utah Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pacific Islands Pennsylvania Puerto Rico-Virgin Islands Rhode Island South Carolina South Dakota Tennessee Texas Vermont Virginia Washington West Virginia Wisconsin Wyoming     Zip:

*Phone:         Fax:    
Please provide a daytime phone number.

E-mail:  

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*Please contact me by:   phone (Mon -Fri, 8:30 am - 5:00 pm MST)     e-mail

*Please send my claim form to me by:    mail     fax     e-mail

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• Guardian 401(k)
• Guardian Variable Annuity

• John Hancock 401(k)
• John Hancock Variable Annuity

 MassMutual
  Financial Group

• MassMutual Financial Group