Please use this form to submit the following types of claims:
Fields marked with a red asterisk ( *) are required.
Upload any claim support material you have, such as Police Reports, Hospital Reports and/or Internal Incident Reports
Accepted file extensions: .pdf, .doc, .docx, .png, .jpg
You may also print and fax this form for processing to: 1-332-777-1286
Claims Customer Support
Claims Fax (332) 777-1286
Phone (866) 481-5262 Ext: 557
145 W 45th Street
New York, NY 10036
Tel (212) 375-3000
Main Fax (888) 389-8061
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