File Online Claim Form
THE ONLINE CLAIM FORM CONTAINS TWO (2) SECTIONS, ALL OF WHICH MUST BE COMPLETED BEFORE THE FORM IS SUBMITTED, INCLUDING THE VERIFICATION ON THE LAST PAGE. YOUR CLAIM WILL NOT BE SUBMITTED UNTIL AFTER YOU COMPLETE THE VERIFICATION AND PRESS THE [GREEN “SUBMIT” BUTTON].
Please print the verification for your records.
To complete the online Claim Form and Release, please click here.
Note: These documents are in PDF format. To view the
documents, you will need Adobe Acrobat Reader on your computer or other internet-enabled device.