ClientZone

Must submit proof of claim with in 60 days from date of service 

service@hccmis.com

HCC Medical Insurance Services, LLC

Attention: Claims Department

P.O Box 2005

Farmington Hills, MI 48333-2005

800-605-2282

Or

317-262-2132

Sample letter for Appeal

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

Seven Corners

Attention: Claims Department

303 Congressional Boulevard

Carmel, IN 46032

800-335-0611

Or

317-575-2656

Claim Form

Accident Questionnaire

Must submit proof of loss

customercare@imglobal.com

International Medical Group

Attention: Claims Department

P.O Box 88500

Indianapolis, IN 46208-0500

800-628-4664

or

317-655-4500

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

HCC Medical Insurance Services, LLC

Attention: Claims Department

P.O Box 2005

Farminton Hills, MI 48333-2005

800-605-2282

Or

317-262-2132

Claimant's Statement

Non-U.S. Claim Form

Accident Questionnaire

Dental Claimant's Statement

Claimant's Statement

Non-U.S. Claim Form

Accident Questionnaire

Dental Claimant's Statement

Claimant's Statement

Non-U.S. Claim Form

Accident Questionnaire

Dental Claimant's Statement

Appeal Form

Claim Form

Authorization Form to Disclose Protected Health Information

GBG Administrative Services Inc.

Co-ordinated Benefit Plans,

LLC on Behalf of Global Benefits Group,

PO Box 2069 Fairhope AL 36533

Toll-Free: 866-669-9004

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

Global Claims Administration

3195 Linwood Road, Suite 201

Cincinnati, OH 45208

US & Canada

800-513-2981

Outside US & Canada

1-513-533-1330

Claim Form

Authorization For Reimbursement Form

Accident Questionnaire

Trip Delay

Must submit proof of loss

service@azimuthrisk.com

Azimuth Risk Solutions

Attention: Claims Department

P.O Box 627

Indianapolis, IN 46206

Claim Form

Authorization-Acknowledgement

Must Inform about claim with in 15 days to insurance company

cmcginnis@irmgroup.com

International Risk Management Group

3359 Rt 413, Suite 100

Doylestown, Pennsylvania 18902

Axis Insurance Company Claim Form

CHUBB Claim Form

HIPPA Authorization Form

Online Claim Form