Before you download a document you will need to obtain the latest version Adobe Acrobat Reader.
All individual claim Loss Reports and Reimbursement Requests have to be submitted electronically via the eMember service. If you are not already an eMember, please access the application form and additional information about this service by clicking on the eMember link on the menu bar. Certain exceptions apply when the paper form (below) may be used.
There are two versions of the form. One version is simply for printing with no capability to input data. The other version allows you to input data directly into the form and then print the form. If you want to save the form after entering data, you must have Adobe Acrobat, which is different than Adobe Acrobat Reader. For instructions on how to prevent Adobe Acrobat Reader from saving temporary form data, click here.
- pdf Loss Reporting Form (41 KB)
- pdf Third Party Administrator Authorization Form (26 KB)
- pdf Social Security Information Form (20 KB) (form to forward to SSA for SS info)