To submit a new claim, please complete this form below and click on the Submit button. Please enter as much information as possible to expedite the investigation process. If you have any questions, please call:

American Claims Management: 1-(866)-671-5042

* Date Of Injury/Illness:
* Social Security Number:
* Employee First Name:
* Employee Last Name:
* Jurisdiction: NoneCaliforniaArizonaNevadaHawaiiIowaOhioUtahColoradoConnecticutDelawareDist. of ColumbiaFloridaGeorgiaIllinoisIndianaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMissouriNebraskaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaOklahomaPennsylvaniaRhode IslandSouth CarolinaTennesseeTexasVermontVirginiaWest VirginiaWisconsinAlaskaArkansasWyomingIdahoMississippiMontanaNorth DakotaOregonPuerto RicoSouth DakotaAlabamaWashingtonLong Shore and Harbor WorkersGuamMulti StateCanadaVirgin Islands
* Policy Number: