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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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