Medical Claim Form

All fields marked with * are required.

Contact Information

Preferred contact information for all future correspondence regarding this claim.

First Name *

Last Name *

Address *

Address 2 (Optional)

City *

State *

Zip Code *

Email Address *

Your email address will never be sold. It will be used to send you important notices.

Office Phone (Optional)

Mobile Phone (Optional)

Home Phone (Optional)

Patient Information

Patient Name *

Patient Address *

Patient City *

Patient State *

Patient Zip Code *

Date of Birth *

Alleged Date of Injury *

First Date of Treatment *

Last Date of Treatment *

Claim Information

Lawsuit Filed? *

Yes No

Insured(s) Named in Claim *

Nature of Alleged Injury (if known) (Optional)

Attachments:

Coverage is subject to all terms, conditions and exclusions of the policy issued and any applicable endorsements.

From advice about a sensitive patient encounter or situation to responding to a written demand from an attorney, we’re here to support you.