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Accidental Death and Dismemberment Claim Form Accidental Death and Dismemberment Claim Form 2026
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- Click ‘Get Form’ to open the Accidental Death and Dismemberment Claim Form in the editor.
- Begin by completing the Claimant Section on the front of the form. Fill in your name, Social Security number, date of birth, and relationship to the insured.
- Read and sign the Authorization and Legal notice section located on the back of the form to ensure compliance.
- Have your doctor complete the Physician’s Statement on the back of this form. Ensure they provide their contact information for verification.
- Answer all questions thoroughly. Missing information can delay your claim process. Be sure to check if there is a new address.
- Describe how the accident occurred in detail, and attach any supporting documents such as an accident report.
- Finally, forward this completed form to your Administrator at the address provided at the top of the form.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2014 | 4.8 Satisfied (180 Votes) |
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Accidental Dismemberment Claim Form. IMPORTANT NOTICE: Written notice of claim must be provided within 90 days of the loss. Written proof of loss must be.Read more
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To file a claim for ADD benefits, complete the Claimants Statement. Your claim may also require your physician to complete an Attending Physicians Statement.Read more