Get the free AD&D Claim Form

Accidental Dismemberment & Catastrophic Loss Claim Form Send to: Group Life Claims, P.O. Box 26035, Leigh Valley, PA 18002-6035 Customer Service: (800) 525-4542, Fax: (610) 807-8266 Secure E-mail:

How to fill out adampd claim form

How to fill out an adampd claim form:

1. Start by entering your personal information at the top of the form. Include your full name, address, contact number, and any other requested details.
2. Next, provide information about the policyholder. This is typically the person who holds the accidental death and dismemberment (AD&D) insurance policy. Include their name, policy number, and any other relevant information.
3. In the "Claimant Information" section, enter the details of the person filing the claim. This could be the policyholder themselves or a beneficiary. Include their name, relationship to the insured, date of birth, and contact information.
4. The next section typically requires you to explain the details of the accident or incident that resulted in the claim. Provide a clear and concise description of what happened, including date, time, and location.
5. Provide any supporting documentation that may be required. This could include medical records, police reports, death certificates, or any other relevant documents. Make sure to submit copies and keep the originals for your records.
6. If you are filing the claim as a beneficiary, you may need to provide additional information such as your relationship to the insured and any relevant beneficiary designation forms.
7. Review the completed form thoroughly before submitting it. Ensure that all the information provided is accurate and complete. If any sections are unclear, reach out to the insurance company for clarification.
8. Finally, sign and date the form to certify that all the information provided is true and correct. Include any other required signatures, such as witnesses or authorized representatives, if applicable.

Who needs an adampd claim form?

1. Individuals who have a personal AD&D insurance policy and are making a claim for themselves in the event of an accident or dismemberment.
2. Beneficiaries of an AD&D insurance policy who need to file a claim on behalf of the insured person in the event of their accidental death or dismemberment.
3. Personal representatives or authorized individuals who have been granted power of attorney to file the claim on behalf of the insured or the beneficiary.

Note: The specific requirements and procedures for filling out an AD&D claim form may vary depending on the insurance company and policy. It is important to carefully follow the instructions provided by the insurer and seek assistance if needed.

For pdfFiller’s FAQs

What is adampd claim form?

The AD&D claim form is a document used to file a claim for Accidental Death and Dismemberment benefits.

Who is required to file adampd claim form?

The beneficiary or legal representative of the deceased person is required to file the AD&D claim form.

How to fill out adampd claim form?

The AD&D claim form should be filled out accurately and completely with all relevant information regarding the accident and the deceased person.

What is the purpose of adampd claim form?

The purpose of the AD&D claim form is to request benefits for accidental death or dismemberment as outlined in the insurance policy.

What information must be reported on adampd claim form?

Information such as the details of the accident, medical records, death certificate, and beneficiary information must be reported on the AD&D claim form.

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