Please enter the required information in the fields provided.
Your claim summary
Claim ID: {{ClaimInfo.ClaimNumber}}
Claim Submitted Date: {{ClaimInfo.SubmittedDate | date:"MM/dd/yyyy 'at' h:mma"}}
claim Submitted By: {{ClaimInfo.SubmittedBy}}
Service Performed: {{ClaimInfo.ServicePerformed}}
Date of Loss: {{ClaimInfo.DateOfLoss | date:'MM/dd/yyyy'}}
Date of Service: {{ClaimInfo.DateOfService | date:'MM/dd/yyyy'}}
Submitted Amount: ${{ClaimInfo.SubmittedAmt}}
Your claim status
Claim Status: {{ClaimInfo.Status}}
Approved Amount: {{ClaimInfo.ApprovedAmt}}
Processing Comments: {{ClaimInfo.ProcessingComment}}
Your claim processing details
Payment Processed Date: {{ClaimInfo.PaymentProcessedDate}}
Payment Type: {{ClaimInfo.PaymentType}}
Payment Sent to: {{ClaimInfo.PaymentSentto}}
For any additional questions regarding your claim status, please utilize the form on the Support section of this site.