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:
*Country:  
*Reporter Address 1:  
  Reporter Address 2:
*City:  
*State:  
*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)


 

WARNING:

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.