HOME PRODUCTS CUSTOMERS AGENTS INVESTORS ABOUT Life Claims Form Please select the type of claim you wish to file: Wellness Benefit Inquiry or Request to be Contacted School or Recreational Coverage Health or Accident Health or Accident - Florida Death Death - Florida Policy Number(s): Patient's Name: Patient's Date of Birth: Patient's Social Security Number: Mailing Address: City: State: ALASKA ALABAMA 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 ZIP: Home Phone: Work Phone: Cell Phone: Fax: E-mail: Desired Contact Method: Home Phone Work Phone Cell Phone Fax Email US Mail 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.

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