Portable Accidental Death and Dismemberment (AD&D) claim forms
Have you added portable benefits coverage to your workplace plan? You’re in the right place.
Start a claim
Use these forms to make a claim through your Portable Benefits Accidental Death & Dismemberment (AD&D) and specific loss coverage.
Download this form and print it, or fill it out in Adobe Reader XI or higher (not your browser) and save.
When you’ve completed your forms, you can submit them to us by email at firstname.lastname@example.org or fax to (204) 946-8783.