Member Protection Claim Form
Please complete all required information to submit claim.
Member Name:
*
First Name
Last Name
Member Account Email Address:
*
example@example.com
Member Account Mobile Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Mailing Address (do not use a PO Box):
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Service Request Incident:
*
-
Month
-
Day
Year
Date
Approximate Time:
Hour Minutes
AM
PM
AM/PM Option
Total Reimbursement Amount:
*
Summary Description of Incident:
*
Explanation of Cost Incurred:
*
Copies of Receipts
*
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of
Additional Receipts - 1
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Additional Receipts - 2
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Authorize Attorney Shield® to verify the details of the claim to include an administrative review of available video footage:
*
I agree
I certify that the information provided is true and correct to the best of my knowledge
*
I agree
Signature
*
Please verify that you are human
*
Submit
Submit
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