Before you download a document you will need to obtain the latest version Adobe Acrobat Reader. To get the free reader simply click on this icon.
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 complete the application form.
Certain exceptions apply when the paper Loss Reporting form (below) may be used. There are two versions of the form: one version is simply for printing with no capability to input data, and 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 (without input) (26 KB) (without input) (38.8 kilobytes in size)
- pdf Loss Reporting Form with Input (41 KB) (with input) (71.8 kilobytes in size)
- pdf TPA Authorization Form (26 KB)
- pdf Social Security Information Form (20 KB) (form to forward to SSA for SS info) (21 kilobytes in size)