General Claim Form (long)
General Claim Form (short)
Accident/Incident Form
Authorization for Medical Access
Personal Representative Authorization for Minor Child(ren)
Other Health Information for Insured or Spouse
Other Health Information for Child
We're here to answer your questions.

Accident/Incident Claim Form

Your Name:
How do you want to be contacted:
No response Needed
Email     Telephone     Fax
Fax #:

Patient Information

*Claim is on:

Employee    Spouse

*Patient's Name:
*Patient's DOB:

Employee Information

*Employer Group Name:
*Employee ID#:
*Last Name:
*First Name:
*City, State, Zip:

Physician Information

*Physician Who Treated the Injury:
*Physician's Address:

Injury Information

*Date of Injury:
*Will you file a claim under Workman's
Compensation or similar law?
Yes     No
*Where did the injury occur:

At work     At home
Other, please specify below:
Was Injury Work Related? Yes     No
*Give complete description below of
HOW and WHERE injury occurred:
What were you doing
the time the injury occurred:
*Is the injury due to
an automobile accident?
Yes   No
*Was another party at fault? Yes   No
*If yes, give name and address
of other party at fault below:

Appeal Information

Check this box if you are appealing claims that have been denied for receipt of this information.

Other Insurance Information

*Has this claim been filed with
another insurance company?
Yes     No
*Other company name:
*Other company address:
Other company city, state, zip:
Other company phone number:
As a means of added security,
we've added visual verification to our contact form.
Please enter the code you see in the box to the left.