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Providing this information does NOT replace the need for a claims adjuster to personally contact you. It does however allow you to document, in great detail, what has occurred.

Please fill out the following online form, and use the Submit button located at the bottom. You may also contact us at 1-866-458-6467 (866-HLTNINS)

Please tell us how we can contact you:
Name:
Street Address:
City:
State:
Zip:
Phone:
What type of claim did you suffer?
When did the loss occur?
Date:
Where did the loss occur?
Street Address:
City:
State:
Zip:
In your own words, please provide
a detailed description of what happened:
List of witness names, telephone numbers, etc.:
Additional questions and/or comments:

 

Note: Please notify us if you do not hear from the carrier within 48 hours.

 

© 2004 - Payne Financial GroupP.O. Box 3089 • Butte, MT 59702-3089 • Ph.866-458-6467 (866-HLTNINS) • FAX 406-494-7641