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Submit injury claim
(800) 741-0415
Submit your injury claim
Where did the injury occur?
Address
Street Address
City
State
Did you report the incident?
Yes
No
Evidence upload
Photos/Videos
PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF
Receipt or bank statement (Proof of visit)
PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF
Did you get medical treatment?
Yes
No
Where did you receive your medical treatment?
Did they file a report? Upload file (Optional)
PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF
Your Full Name
Email
*
Phone
*
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Submit Injury claim
(800) 741-0415
