Claim Forms

Note: Insurance company makes decision on claims. Download appropriate policy claim form.

Tokio Marine HCC Medical Insurance Services Group	Download Claim Forms	Email	Fax	Mail	Insurance Company Phone
Atlas America	Claim Form Claimant Appeal Request Form Lost Checked Luggage Accident Questionnaire	Must submit proof of claim with in 60 days from date of service service@hccmis.com	317-262-2140	HCC Medical Insurance Services, LLC Attention: Claims Department P.O Box 2005 Farmington Hills, MI 48333-2005	800-605-2282 Or 317-262-2132
Atlas International
Visitor Secure
Student Secure Select - Including USA
Student Secure Select - Excluding USA
Student Secure Budget - Including USA
Student Secure Budget - Excluding USA
Student Secure Smart - Including USA
Student Secure Smart - Excluding USA
Seven Corners	Download Claim Forms	Email	Fax	Mail	Insurance Company Phone
Inbound USA	Medical Claim Form/Proof of Loss Form Authorization Form to Disclose Protected Health Information	Must send claim form and payment receipts with in 90 days from date of service claims@sevencorners.com	317-575-2256	Seven Corners Attention: Claims Department 303 Congressional Boulevard Carmel, IN 46032	800-335-0611 Or 317-575-2656
Inbound Guest
Inbound Immigrant
Liaison Continent Plan A
Liaison Continent Plan B
Liaison Continent Plan E
Liaison Continent Plan F
Liaison Majestic - Including USA
Liaison Majestic - Excluding USA
Liaison International
Liaison International Option 1
Liaison International Option 2
MCIS Flexible Travel Insurance - Including USA
MCIS Flexible Travel Insurance - Excluding USA
Liaison Student	Claim Form
International Medical Group (IMG)	Download Claim Forms	Email	Fax	Mail	Insurance Company Phone
Visitors Care	Claim Form Accident Questionnaire	Must submit proof of loss customercare@imglobal.com	317-655-4505	International Medical Group Attention: Claims Department P.O Box 88500 Indianapolis, IN 46208-0500	800-628-4664 or 317-655-4500
Patriot America
Patriot America Plus
Patriot Platinum America
Patriot GoTravel America
Patriot International
Patriot Platinum International
Patriot GoTravel International
Patriot Green America
Patriot Green International
Patriot Exchange Program
Student Health Advantage - Including USA
Student Health Advantage - Excluding USA
USI Affinity Travel Insurance Services	Download Claim Forms	Email	Fax	Mail	Phone Company Phone
Visit USA HealthCare - Budget	Claimant's Statement Non-U.S. Claim Form Accident Questionnaire Dental Claimant's Statement	Must submit proof of claim with in 60 days from date of service service@hccmis.com	317-262-2140	HCC Medical Insurance Services, LLC Attention: Claims Department P.O Box 2005 Farminton Hills, MI 48333-2005	800-605-2282 Or 317-262-2132
Visit USA HealthCare - Standard
Visit USA HealthCare - Superior
Inter Medical	Claimant's Statement Non-U.S. Claim Form Accident Questionnaire Dental Claimant's Statement
WorldMed	Claimant's Statement Non-U.S. Claim Form Accident Questionnaire Dental Claimant's Statement
Study USA Healthcare	Claimant's Statement Non-U.S. Claim Form Accident Questionnaire Dental Claimant's Statement
Study USA Healthcare Preferred
Trawick International	Download Claim Forms	Email	Fax	Mail	Insurance Company Phone
Safe Travels for Visitors to the USA	Claim Form Authorization Form to Disclose Protected Health Information	Must submit proof of loss with in 90 days from date of service	NA	GBG Administrative Services Inc. 26741 Portola Pkwy 1E # 527 Foothill Ranch CA 92610	Inside USA: 877-916-7920 Outside the U.S. (collect): 949-916-7941
Safe Travels International
Safe Travels International Cost Saver
Safe Travels USA
Safe Travels USA Comprehensive
Safe Travels USA Cost Saver
Global Underwriters	Download Claim Forms	Email	Fax	Mail	Insurance Company Phone
Diplomat America	Claim Form Death Claim Form Dismemberment Claim Form Baggage Loss, Theft or Damage Authorization Form to Disclose Protected Health Information	Must submit proof of loss with in 60 days from date of service claims@globalunderwriters.com	513-533-9416	Global Claims Administration 3195 Linwood Road, Suite 201 Cincinnati, OH 45208	US & Canada 800-513-2981 Outside US & Canada 1-513-533-1330
Diplomat Long Term
Diplomat International
Azimuth Risk Solutions	Download Claim Forms	Email	Fax	Mail	Insurance Company Phone
Beacon America	Claim Form Authorization For Reimbursement Form Accident Questionnaire Trip Delay	Must submit proof of loss service@azimuthrisk.com	317-423-9620	Azimuth Risk Solutions Attention: Claims Department P.O Box 627 Indianapolis, IN 46206	888-201-8850
Beacon International		Must submit proof of loss service@azimuthrisk.com	317-423-9620		888-201-8850
Petersen International Underwriters	Download Claim Forms	Email	Fax	Mail	Insurance Company Phone
International Major Medical	Claim Form Authorization-Acknowledgement	Must Inform about claim with in 15 days to insurance company cmcginnis@irmgroup.com	215-794-1498	International Risk Management Group 3359 Rt 413, Suite 100 Doylestown, Pennsylvania 18902	888-622-4764
USAway International Major Medical
The Bridge Plan

Associated Insurance Companies