Create a New Claim

  • Child's Information

  • Date Format: MM slash DD slash YYYY
  • Guardian's Information

  • Person Submitting Claim

  • Claim Information

  • Date Format: MM slash DD slash YYYY
  • Do not include confidential information on any of your attached files such as social security number, date/place of birth, mother's maiden name, etc.
    Drop files here or

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statement of claim for any insurance benefits containing any materially false information, or conceals for the purpose of misleading, any information concerning any fact material thereto, and any person who in connection with such application or claim, who knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report shall be subject to criminal and civil penalties.