Accident Benefits Claim Referral Form

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  • LEGAL REPRESENTATIVE (if applicable)


  • MM slash DD slash YYYY
  • DOCUMENTATION RECEIVED (Please forward to us)

    Please forward to us by fax, mail or attach by using "Upload Documents" button below. You can upload a single ZIP file or upload individual files for each type of document received
  • Please provide a list of the documents received in the field below:
  • Drop files here or
    Accepted file types: jpg, jpeg, png, pdf, doc, docx, gif, xls, xlsx, csv, txt, rtf, Max. file size: 64 MB.
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