Skip to content
Home
Who We Are
Our History
Our Locations
Our Social Contributions
What We Do
Claims Management
Compliance
Information Technology
Claims
Claims Management & Administration
Financial Administration
MI Reporting
Loss Runs
Compliance
Medicare Compliance & Reporting
U.S., U.K. & Lloyd’s Regulatory Compliance
Information Technology
IT Infrastructure
CLAIMS System
Business Continuity & Disaster Preparedness
Client Access
We are a TPA well equipped to handle all of your claims needs.
Contact Us
Submit a Claim
Contact Form
Careers
Remote Access
Client Login
X
Search for:
Search Button
Home
Who We Are
Our History
Our Locations
Our Social Contributions
What We Do
Claims Management
Compliance
Information Technology
Claims
Claims Management & Administration
Financial Administration
MI Reporting
Loss Runs
Compliance
Medicare Compliance & Reporting
U.S., U.K. & Lloyd’s Regulatory Compliance
Information Technology
IT Infrastructure
CLAIMS System
Business Continuity & Disaster Preparedness
Client Access
We are a TPA well equipped to handle all of your claims needs.
Contact Us
Submit a Claim
Contact Form
Careers
Remote Access
Client Login
X
Contact Us
/
Submit A Claim
Submit A Claim
Submit Claim
Please enable JavaScript in your browser to complete this form.
1
Tendering Party
2
Insured
3
Claimant
4
Assigment
5
Attachments
6
Verification
Your First name
*
Your Last Name
*
Your Company Name
*
Address
*
Address Line 1
City
Choose a State
Armed Forces Americas
Armed Forces Canada, Europe, & Middle East
Alaska
Alabama
Armed Forces Pacific
Arkansas
American Samoa
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Federated States of Micronesia
Georgia
Guam
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Marshall Islands
Michigan
Minnesota
Missouri
Northern Mariana Islands
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Palau
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Virgin Islands
Vermont
Washington
Wisconsin
West Virginia
Wyoming
State
Code Postal
Phone Number
*
Fax Number
Email Address
*
Your Claim Number
Next
Insured Information
Same as tendering party.
Insured Company Name
Insured Last Name
*
Insured First Name
*
Policy Number
*
Effective Date From
*
Effective Date To
*
Insured Address
*
Address Line 1
City
Choose a State
Armed Forces Americas
Armed Forces Canada, Europe, & Middle East
Alaska
Alabama
Armed Forces Pacific
Arkansas
American Samoa
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Federated States of Micronesia
Georgia
Guam
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Marshall Islands
Michigan
Minnesota
Missouri
Northern Mariana Islands
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Palau
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Virgin Islands
Vermont
Washington
Wisconsin
West Virginia
Wyoming
State
Code Postal
Phone Number
*
Phone Type
Cell
Home
Work
Secondary Phone Number
Phone Type
Cell
Home
Work
Email Address
Previous
Next
Claimant Company Name
Claimant Last Name
Claimant First Name
Claimant Address
Address Line 1
City
Choose a State
Armed Forces Americas
Armed Forces Canada, Europe, & Middle East
Alaska
Alabama
Armed Forces Pacific
Arkansas
American Samoa
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Federated States of Micronesia
Georgia
Guam
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Marshall Islands
Michigan
Minnesota
Missouri
Northern Mariana Islands
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Palau
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Virgin Islands
Vermont
Washington
Wisconsin
West Virginia
Wyoming
State
Code Postal
Phone Number
Previous
Next
Type of Assignment
*
Choose an Assignment Type
Liability
Property
Construction Defect
Bodily Injury
Auto
Loss Description
*
Date of Loss/Accident
Loss Location
Same as Insured
Address
*
Address Line 1
City
Choose a State
Armed Forces Americas
Armed Forces Canada, Europe, & Middle East
Alaska
Alabama
Armed Forces Pacific
Arkansas
American Samoa
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Federated States of Micronesia
Georgia
Guam
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Marshall Islands
Michigan
Minnesota
Missouri
Northern Mariana Islands
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Palau
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Virgin Islands
Vermont
Washington
Wisconsin
West Virginia
Wyoming
State
Code Postal
Assigment
Previous
Next
File Upload
Click or drag files to this area to upload.
You can upload up to 10 files.
*Acceptable File Formats: jpeg, jpg, gif, png, bmp, tiff, tif, pdf, doc, docx, xls, xlsx, txt, wpd
Previous
Next
Updating preview…
This is a preview of your submission. It has not been submitted yet!
Please take a moment to verify your information. You can also go back to make changes.
Previous
Submit
Submit Claim
Your First Name
Your Last Name
Your Company
Your Address
City
State
Choose a State
Armed Forces Americas
Armed Forces Canada
Europe, & Middle East
Alaska
Alabama
Armed Forces Pacific
Arkansas
American Samoa
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Federated States of Micronesia
Georgia
Guam
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Massachusetts
Maryland
Maine
Marshall Islands
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Palau
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Virgin Islands
Vermont
Washington
West Virginia
Wyoming
Zip Code
Phone Number
Ext.
Fax Number
Email
Your Claim Number
Insured information
Same as tendering party.
Insured Company Name
Insured Last Name
Insured First Name
Policy Number
Effective Date From
Effective Date To
Insured Address
City
State
Choose a State
Armed Forces Americas
Armed Forces Canada
Europe, & Middle East
Alaska
Alabama
Armed Forces Pacific
Arkansas
American Samoa
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Federated States of Micronesia
Georgia
Guam
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Massachusetts
Maryland
Maine
Marshall Islands
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Palau
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Virgin Islands
Vermont
Washington
West Virginia
Wyoming
Phone Number
Ext.
Cell
Home
Work
Secondary Phone Number
Ext.
Cell
Home
Work
Email
Claimant Company Name
Claimant Last Name
Claimant First Name
Claimant Address
City
State
Choose a State
Armed Forces Americas
Armed Forces Canada
Europe, & Middle East
Alaska
Alabama
Armed Forces Pacific
Arkansas
American Samoa
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Federated States of Micronesia
Georgia
Guam
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Massachusetts
Maryland
Maine
Marshall Islands
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Palau
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Virgin Islands
Vermont
Washington
West Virginia
Wyoming
Zip Code
Phone Number
Type of Assignment
Liability
Property
Construction Defect
Bodily Injury
Auto
Loss Description
Date of Loss/Accident
Loss Location
Same as Insured
Address
City
State
Choose a State
Armed Forces Americas
Armed Forces Canada
Europe, & Middle East
Alaska
Alabama
Armed Forces Pacific
Arkansas
American Samoa
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Federated States of Micronesia
Georgia
Guam
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Massachusetts
Maryland
Maine
Marshall Islands
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Palau
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Virgin Islands
Vermont
Washington
West Virginia
Wyoming
Zip Code
Assigment
Attachment Info
Send