Create a New Claim

Create a New Claim
Child's Information
Name*
First Last
Date of Birth
MM slash DD slash YYYY
Gender
Grade*
Guardian's Information
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Daytime Phone
Which school is the claim being filed for?
Person Submitting Claim
Name*
First Last
Phone*
Email*
Claim Information
Type of Departure*
Date of Withdrawal/Dismissal*
MM slash DD slash YYYY
Support Documentation
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

Max. file size: 100 MB.
Reason for Departure*
Captcha (required to eliminate spam)*
What does 4 + 6 equal?
Comments
This field is for validation purposes and should be left unchanged.

NOTE:
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.

Create a New Claim

Create a New Claim

Child's Information

Guardian's Information

Person Submitting Claim

Claim Information