File a Claim
Group Accident Insurance Claims


Accident Claim Form

Please provide a date and complete description of your accident. You can provide this information in the designated space on the claim form.

If the accident resulted from the use of a motor vehicle(s), a copy of the police or accident report is required. If your injury occurred on the job, a first report of injury filed with your employer must be attached to the completed claim form.

If you were first treated in an emergency room, a copy of the hospital discharge papers is required to verify the first date of treatment, diagnosis, and procedure.

Please include all dates of treatment and charges incurred due to the accident.

Please date and sign all required forms where indicated.