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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. 

Claim forms

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 or fax to (204) 946-8783. 

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I have coverage through my employer

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I bought coverage through an advisor

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