Follow the steps to accurately complete your claim form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with Part I, the Policyholder’s Statement. Fill in the policyholder information, including policy number, name, email address, and address. Ensure that the form is completed in full and signed by an official representative.
3. Proceed to Part II, the Claimant’s Statement. This section should be completed by the claimant or their parent or guardian. Enter the claimant's name, date of birth, social security number, and address.
4. Provide details about the claimant's condition, specifying whether the claim relates to an accident or sickness. Include the date and place of the accident or the first symptoms of the illness.
5. Attach any required documentation, such as medical records or incident reports, depending on the nature of the claim.
6. Review all sections to ensure they are fully completed and sign where indicated. After double-checking for accuracy, save your changes.
7. Download, print, or share the completed form as necessary. Retain copies of all submitted documents for your records.

We encourage you to complete your documents online for a smoother claim process.