Online Claim Reporting
United Home Life Insurance Company / United Farm Family Life Insurance Company

Claim Disclaimer

By furnishing this form and starting the claims-reporting process, we do not waive any right, admit any claim, or verify or commit to coverage for your loss.
(*indicates a required field)

Person Reporting Claim Information
*Person Reporting Claim:
*Reporter Name: (first)     (last)   
  Business Name:  
*Reporter Address 1:   
  Reporter Address 2:  
*Zip Code:  -  
*Reporter Phone:   
  Relationship to Insured:  
  Reporter E-mail:   If a valid Email address is provided, a confirmation
will be sent containing your First Notice of Loss number for reference
Insured Information
*Insured Name: (first)   (middle)  (last)  
*Insured Birthdate:  (mm/dd/yyyy) 
  Insured Social Security Number:   
  Insured State of Residency:
  Policy Number:   
Claim Information
*Date of Death:  (mm/dd/yyyy)    
*Cause of Death:
  Funeral Home Name:  
  Funeral Home Phone:   
  Additional Information and/or
  Special Mailing Instructions:
 ( characters remaining)



A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete or misleading information commits a felony.