Medical & Accidental Death
PROOF OF LOSS

Policyholder's Information

Name: Date of Loss: mm/dd/yyyy

Address: City:

State: ZIP code:

Injured Person's Information     Same as Policyholder above

Name: Address:

City: State:     ZIP :

Date of Birth: mm/dd/yyyy Relation to Policyholder:

Injured Person's Employer (on date of loss)

Name: Phone:

Address: City:

State: ZIP code:

All Available Insurance       Injured Person has no additional insurance.
You must list: Personal Injury Protection (PIP), Medical Payments, Private Health Insurance & Medicare.

   Carrier Name:          Polciy #:

Additional Information

1. Please Indicate the type of claim being submitted:
   Hospital Room Indemnification
   Excess Accident Medical Expense Reimbursement
   Ambulance Fee Reimbursement
   Accidental Death
2. Did injury occur while participating in organized sports?
     No
     Yes

3. Please provide us with a narrative description of the facts and circumstances of this accident / loss:


Please be sure all information is correct before you continue.

*Policyholder's Information*
Name:		Date of Loss:	mm/dd/yyyy
Address:		City:
State:		ZIP code:
*Injured Person's Information* Same as Policyholder above
Name:		Address:
City:		State:	ZIP :
Date of Birth:	mm/dd/yyyy	Relation to Policyholder:
*Injured Person's Employer (on date of loss)*
Name:		Phone:
Address:		City:
State:		ZIP code:
*All Available Insurance* Injured Person has no additional insurance. You must list: Personal Injury Protection (PIP), Medical Payments, Private Health Insurance & Medicare.
Carrier Name: Polciy #:
*Additional Information*
1. Please Indicate the type of claim being submitted: Hospital Room Indemnification Excess Accident Medical Expense Reimbursement Ambulance Fee Reimbursement Accidental Death		2. Did injury occur while participating in organized sports? No Yes
3. Please provide us with a narrative description of the facts and circumstances of this accident / loss:
Please be sure all information is correct before you continue.