Life Claims Form

Please select the type of claim you wish to file:
Policy Number(s):
Patient's Name:
Patient's Date of Birth: 
Patient's Social Security Number: 
Mailing Address: 
City: State: ZIP: 
Home Phone: 
Work Phone: 
Cell Phone: 
Fax: 
E-mail: 
Desired Contact Method:

Additional supporting information required:

  • The physician’s, clinic, or facility receipt showing the specific wellness exam performed and the date it was performed. You may:
    • upload it below; or
    • fax it to us at 1-800-693-7507; or
    • mail it to us at P. O. Box 703, Elba, AL 36323.
  • If filing under a Critical Illness policy, we will also need the charge for the exam.

ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO RESTITUTION, FINES OR CONFINEMENT IN PRISON, OR ANY COMBINATIONS THEREOF.

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.