Accidental Death and Dismemberment Claim Form Accidental Death and Dismemberment Claim Form 2026

1. Click ‘Get Form’ to open the Accidental Death and Dismemberment Claim Form in the editor.
2. 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.
3. Read and sign the Authorization and Legal notice section located on the back of the form to ensure compliance.
4. Have your doctor complete the Physician’s Statement on the back of this form. Ensure they provide their contact information for verification.
5. Answer all questions thoroughly. Missing information can delay your claim process. Be sure to check if there is a new address.
6. Describe how the accident occurred in detail, and attach any supporting documents such as an accident report.
7. Finally, forward this completed form to your Administrator at the address provided at the top of the form.

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