Life Claims Form

Please select the type of claim you wish to file:
To be completed by:
  • The principal for accidents while attending school or while participating in a school sponsored event/sport.
  • The coach may also complete for injuries received while participating in a school sponsored sporting event.
  • The Recreational Director for injuries under Recreational Coverage.
  • A parent or guardian for accidents occurring away from school other than participating in a school sponsored event/sport.

School or Rec. Dept. Name:
Policy Number(s):
Child's Name:
Insured's Date of Birth:
Date of Accident:
Time:
Grade
Teacher:
Your Name:
Title:
Mailing Address:
City:State:ZIP:
Parent or School Phone:
Your Phone:
Fax:
E-mail:
Desired Contact Method:
Claim Type:
Where did the accident happen?
How did the accident happen?
Type of Injury:
Date of First Treatment:
Is this an aggravation of a condition that existed previously?
If yes, date of original injury/sickness:

Additional supporting information required:

  • Please mail supporting documentation to us at P. O. Box 703, Elba, AL 36323; or fax it to us at 1-800-693-7507; or upload it below.
  • Claim forms are available below or under the “Customers” tab. Select “Forms”; School Accident/Football, recreational Sports Insurance Claim Form. The physician should complete Section 2 and the parent/guardian should complete Section 3 only if they wish payment to go directly to the hospital or physician. This notification is accepted in lieu of Section 1. We do accept standard attending physician’s statements.
  • If you need to file a claim on your group catastrophic policy (for claims exceeding $25,000) please contact your school or athletic official or call us at 1-800-798-2317.
Fraud Statement:
Acknowledge fraud statement
Fraud Statement Acknowledged By:

Forms

Select a file to upload with your claim form:

If uploading a file, please be patient after clicking the submit button to allow the file time to upload.

I certify that the above person’s accident occurred as described above to the best of my knowledge.