Injury & Illness Claim Form

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Injury & Illness Claim Form

To submit an injury or illness (disability) claim, complete the form below, or you can stop by any branch location or call us at 888.213.2848. To be eligible for coverage, you must have an active Injury & Illness policy on your American 1 loan and are excused from work by a doctor for at least 14 days.

* Required Fields

Today's Date:

/ /

Account Number:

First day unable to work as determined by physician:

/ /

Full Name:

Phone Number (Including area code):

Email:

Address :

Address 2:

City:

State:

ZIP:

Date of Birth:

/ /

Please Acknowledge:

After submitting your claim, you will receive a packet of documents from Securian Financial via mail. You must fill out these documents and return them to Securian for their claim review. Please note that these documents may take some time to arrive. If you have questions regarding your claim after you've returned the documents, contact Securian at 1-800-328-9442.

Security Code: