Submit a Claim - Page 1

Contact Information:
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Alternative or Previous Name (If applicable, provide all information)

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All communications from the Claims Administrator will be directed to the information provided below.

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Please Note: The email address provided above will be used only for communication regarding your claim form. You will also receive an email at this email address after Final Approval if your claim form is deemed eligible, prompting you to select how you’d like to be paid. You can receive your payment via a variety of digital options such as digital debit card or PayPal, or you can elect to receive a check. Please keep a valid email address on file with the Claims Administrator.