Start Your Claim

We understand the loss of a loved one is very stressful, and we’re here to help in any way we can. During this process, please feel free to reach out at any time.

Please fill out and submit the required information through the form below. It is also helpful if you fill out the non-required information as best you can. Using this electronic form enables us to pre-fill much of the claim packet for easier completion. Submitting this form officially notifies us and starts the claim process. We will contact you or the beneficiary listed to follow up and advise you of the next steps in the process.

* INDICATES REQUIRED FIELD -- Please correct the errors noted below to complete submission.

Tell Us About Yourself

Prefix

First Name *

Middle Initial

Last Name *

Suffix

Phone Number *

Email Address *

Role * Please let us know if you are a beneficiary, a funeral home representative, or other. Other would be anyone besides the beneficiary or funeral home representative.

Address A state is only required if country is United States. If the address is for military personnel please indicate the military installation (i.e. APO, FPO) within the City field, and choose the proper state designator (AA, AE, AP) within the state dropdown along with the military post office box number and any other identifying information in the Address fields. Country Address1 Address2 City State Zipcode

Tell Us About the Deceased

Prefix

First Name *

Middle Initial

Last Name *

Suffix

Policy/Contract Number or Social Security Required *

Policy/Contract Number

Additional Policy/Contract Number

Social Security Number

Date of Birth *

Date of Death *

Cause of Death* The condition or conditions that led to the insured's passing. Often times this is available on the death certificate. This could be a disease, injury, or complication directly causing the death just to provide some examples.

Manner of Death * The circumstances that resulted in the death of the insured. Some examples are homicide, suicide or accident. Often times this information is available on the death certificate. If you are uncertain of the manner of death please choose 'Unknown'.

Country of Death *

Do you have any information concerning the beneficiary?

Do you have any information concerning the funeral home/obituary?

Beneficiary Information

Beneficiary TypePlease select whether the beneficiary is a person or an organization.

Organization Type Please select whether the organization is a company, trust, estate, or other.

Name

Address Country Address1 Address2 City State Zipcode

Phone Number

Email Address

EIN This is the employee’s federal identification number.

SSN

Prefix

First Name

Middle Initial

Last Name

Suffix

Date of Birth

Phone Type Please select the type of phone associated with the number you’ve provided. If you would like to received text message alerts please provide your cell phone number.

Phone Number

Email Address A state is only required if country is United States. If the address is for military personnel please indicate the military installation (i.e. APO, FPO) within the City field, and choose the proper state designator (AA, AE, AP) within the state dropdown along with the military post office box number and any other identifying information in the Address fields.

Would you like to receive status alerts? This option allows you to enroll in alerts related to your claim. Alerts will be sent to you based off your preferences when documents are received, and when the claim reaches certain statuses. Both email and text alerts are available.

Email Text Message and data rates may apply Terms and Conditions

Please provide your mobile number

Please confirm your mobile number

Role What is the beneficiary’s relationship to the insured?

Social Security Number

Funeral Home/Obituary Information

Funeral Home Name

Funeral Home Website

Funeral Home Address Street City State Zipcode

Funeral Home Email Address

Funeral Home Phone Number

Funeral Home Fax Number

Funeral Home Assignment This is where all or a portion of the benefit is assigned to be used to cover funeral home costs.

Date of Obituary When was the obituary published online or in the newspaper?

Newspaper of Obituary Which newspaper was the obituary published in?

The information collected in this form by Protective will be used to offer you services that meet your needs and for other business purposes. Please visit our Privacy Policy for more information about our information practices, including information about your privacy choices.