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MAIL OR FAX YOUR CLAIM TO US AT: 2026
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- Click ‘Get Form’ to open the MAIL OR FAX YOUR CLAIM TO US AT: document in the editor.
- Begin by entering your Policy Number, Claim Number, and Date at the top of the form. Ensure these details are accurate for a smooth processing experience.
- In the CLAIMANT’S INFORMATION section, fill in your name, date of birth, gender, marital status, and relationship to the policy owner. If you are a dependent and a full-time student, check the appropriate box.
- Next, provide the POLICYOWNER’S INFORMATION including their name, address, contact numbers, and email. This ensures that all communications are directed correctly.
- For ACCIDENT INFORMATION, specify the date of the accident and whether it was an on-job or off-job incident. Describe the accident in detail to provide context for your claim.
- Review the REQUIRED DOCUMENTATION section carefully. Attach all necessary bills and reports as specified to support your claim.
- Finally, sign and date the form at the bottom. Your signature confirms that you acknowledge any applicable fraud warnings.
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Related links
Jun 8, 2026 If youre in the U.S., fax your application to 844-531-7818 . If youre outside the U.S., fax your application to 248-524-4260 . Option 5: WithRead more
You may fax your claim to us at 1-800-430-4188. Please be assured that your You will usually receive a response from us in the mail within 10 business daysRead more