Accidental death or dismemberment
How to make a claim
Use this form to make a claim for accidental death, dismemberment or specific loss.
To submit a claim:
- Print the appropriate form, and complete Part 1.
- Have your doctor (or your child’s doctor) fill out Part 2.
- When both parts are completed, please send a scanned copy to us via email at email@example.com or by fax at (204) 946-8783.
In light of COVID-19, we ask that you do not mail these forms to us.