CLAIM FORM REQUEST

This handy online form is to give your Connell Team agents a "heads up".  Your agent will fill out the necessary claim forms, secure authorized signatures and written statements from the policy owner and doctors (if applicable).  Once proper documentation has been submitted, your claim will be forwarded and processed usually within 3 business days.  If you need help, call 254 554-0909.  This form submission DOES NOT guarantee payment.  This form is designed to help YOU help your agent get your claim processed faster and more efficently.  Our company can only pay eligible cash benefits based on information provided by you and/or your doctors.

CLICK HERE FOR SECURE FORM

Your Email Address: *
Employer/Company Name *
Policyowner's name *
Policyowner's Social Security Number *
Contact Phone *
Covered Patient's Name *
Patient's relationship to policyowner *
Treatment Date(s) *
Type of Claim Requested (check all that apply) * Accidental Injury
Off Job Injury Disability
Off Job Sickness Disability
Surgery
Hospital Confinement
Follow up treatments
Cancer Wellness/Screening
Cancer Treatment
Dental Wellness
Dental Treatment
Vision Wellness
Vision Surgery/Other
Other (list in Notes below)
List Your Policy Numbers
Treatment Center Location and City *
Doctors name and phone *
Treatment details *
Notes to Agent
Did you call your agent before seeking treatment? * Yes
No
* Required