National Security Group, Inc. - Insuring your world.

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.
Fraud Statement:	Any person who knowingly and with intent to injure, defraud, or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony.
Acknowledge fraud statement
Fraud Statement Acknowledged By:	Enter your name
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.