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Report a Claim
Please fill in the requested information and submit your claim electronically. One of our claim representatives will contact you to confirm receipt of your submission and to discuss what can be expected.
Completed by:*
Relationship to Policyholder:*
This notice is being given on behalf of*

IndividualGroupBoth
Report Date and Time*

MonthDayYear
HourMinutesAM/PM Option
Who may we contact about this notice?
Contact 1*

First NameLast Name
Contact 1 Relationship to Policyholder*
Contact 1 Phone Number*

Area CodePhone Number
Contact 2

First NameLast Name
Contact 2 Relationship to Policyholder
Contact 2 Phone Number

Area CodePhone Number
Insured/Policyholder Information
Insured Name*
Policy Number*
Insured Preferred Phone Number*

Area CodePhone Number
Insured Email Address*
example@example.com
Insured Preferred Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Information
Date of Treatment*

MonthDayYear
Patient Name*
Patient Date of Birth*

MonthDayYear
Patient Gender*

MaleFemale
Additional Information
Type of Notification

Attorney Lien/DPCCyberDeposition AssistDUEIDPR ReimbursementInvestigationLawsuitMedicare/Medicaid ReimbursementNotice of Intent to Initiate LitigationRespondent in DiscoveryTrial Assist
Date of Service

MonthDayYear
County
If you would like to work with a specific defense attorney, please include his/her name and the firm name (if known).
Defense Attorney Name
Defense Attorney Firm Name
Additional Comments
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Report a Claim

Insured/Policyholder Information

Patient Information

Additional Information