Claims Forms
The forms below are for Third-Party Administrator and Claims Administrator use only. If you are not a Claims Administrator or do not represent a Third-Party Administrator, please complete the contact us form below and we will reply with the appropriate information to report your claim.
Right click and “save link as” or “save target as” to utilize the interactive forms. Interactive forms will not work within the browser window.
- First Report
- Supplemental Report
- Auto / GL First Report
- Third Party Administrator Approval Application
Reimbursement Forms
Requests for reimbursement should be sent to the Safety National claims contact responsible for the file. Please complete and sign the appropriate form below and include a detailed payment listing with summary of all payments made on the claim by payment category (i.e. indemnity, medical expense, etc.).
- Reimbursement Request Specific Excess
- Reimbursement Request Aggregate Excess
- Reimbursement Request Specific Excess (pro-rated expenses)
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