Claim Forms

Fax Completed Claim Forms to 1-800-354-5030

If you don’t see the claim form you are searching for please email us at customerservice@esupplemental.com

img.wp-smiley,img.emoji{display:inline !important;border:none !important;box-shadow:none !important;height:1em !important;width:1em !important;margin:0 .07em !important;vertical-align:-.1em !important;background:none !important;padding:0 !important;}.strong-view-id-1 .wpmtst-testimonial-heading,.strong-view-id-1 .wpmtst-testimonial-content p,.strong-view-id-1 .wpmtst-testimonial-content a.readmore,.strong-view-id-1 .wpmtst-testimonial-client div,.strong-view-id-1 .wpmtst-testimonial-client a{color:#000;}.site-title a{background:url("https://cdn-bfanc.nitrocdn.com/nleqNnWYQsinXpeuNAIDvFMJCTyRCynP/assets/static/optimized/rev-14a30aa/wp-content/uploads/2018/04/esupplemental.jpg") no-repeat !important;}.site-title a.nitro-lazy{background-image:none !important;}body.custom-background{background-image:url("https://cdn-bfanc.nitrocdn.com/nleqNnWYQsinXpeuNAIDvFMJCTyRCynP/assets/static/optimized/rev-14a30aa/wp-content/uploads/2018/04/stripe_bg.png");background-position:left top;background-size:auto;background-repeat:repeat;background-attachment:scroll;}body.custom-background.nitro-lazy{background-image:none !important;}button#responsive-menu-button,#responsive-menu-container{display:none;-webkit-text-size-adjust:100%;}@media screen and (max-width: 1023px){#responsive-menu-container{display:block;position:fixed;top:0;bottom:0;z-index:99998;padding-bottom:5px;margin-bottom:-5px;outline:1px solid transparent;overflow-y:auto;overflow-x:hidden;}#responsive-menu-container .responsive-menu-search-box{width:100%;padding:0 2%;border-radius:2px;height:50px;-webkit-appearance:none;}#responsive-menu-container.push-left,#responsive-menu-container.slide-left{transform:translateX(-100%);-ms-transform:translateX(-100%);-webkit-transform:translateX(-100%);-moz-transform:translateX(-100%);}.responsive-menu-open #responsive-menu-container.push-left,.responsive-menu-open #responsive-menu-container.slide-left{transform:translateX(0);-ms-transform:translateX(0);-webkit-transform:translateX(0);-moz-transform:translateX(0);}#responsive-menu-container.push-top,#responsive-menu-container.slide-top{transform:translateY(-100%);-ms-transform:translateY(-100%);-webkit-transform:translateY(-100%);-moz-transform:translateY(-100%);}.responsive-menu-open #responsive-menu-container.push-top,.responsive-menu-open #responsive-menu-container.slide-top{transform:translateY(0);-ms-transform:translateY(0);-webkit-transform:translateY(0);-moz-transform:translateY(0);}#responsive-menu-container.push-right,#responsive-menu-container.slide-right{transform:translateX(100%);-ms-transform:translateX(100%);-webkit-transform:translateX(100%);-moz-transform:translateX(100%);}.responsive-menu-open #responsive-menu-container.push-right,.responsive-menu-open #responsive-menu-container.slide-right{transform:translateX(0);-ms-transform:translateX(0);-webkit-transform:translateX(0);-moz-transform:translateX(0);}#responsive-menu-container.push-bottom,#responsive-menu-container.slide-bottom{transform:translateY(100%);-ms-transform:translateY(100%);-webkit-transform:translateY(100%);-moz-transform:translateY(100%);}.responsive-menu-open #responsive-menu-container.push-bottom,.responsive-menu-open #responsive-menu-container.slide-bottom{transform:translateY(0);-ms-transform:translateY(0);-webkit-transform:translateY(0);-moz-transform:translateY(0);}#responsive-menu-container,#responsive-menu-container:before,#responsive-menu-container:after,#responsive-menu-container *,#responsive-menu-container *:before,#responsive-menu-container *:after{box-sizing:border-box;margin:0;padding:0;}#responsive-menu-container #responsive-menu-search-box,#responsive-menu-container #responsive-menu-additional-content,#responsive-menu-container #responsive-menu-title{padding:25px 5%;}#responsive-menu-container #responsive-menu,#responsive-menu-container #responsive-menu ul{width:100%;}#responsive-menu-container #responsive-menu ul.responsive-menu-submenu{display:none;}#responsive-menu-container #responsive-menu ul.responsive-menu-submenu.responsive-menu-submenu-open{display:block;}#responsive-menu-container #responsive-menu ul.responsive-menu-submenu-depth-1 a.responsive-menu-item-link{padding-left:10%;}#responsive-menu-container #responsive-menu ul.responsive-menu-submenu-depth-2 a.responsive-menu-item-link{padding-left:15%;}#responsive-menu-container #responsive-menu ul.responsive-menu-submenu-depth-3 a.responsive-menu-item-link{padding-left:20%;}#responsive-menu-container #responsive-menu ul.responsive-menu-submenu-depth-4 a.responsive-menu-item-link{padding-left:25%;}#responsive-menu-container #responsive-menu ul.responsive-menu-submenu-depth-5 a.responsive-menu-item-link{padding-left:30%;}#responsive-menu-container li.responsive-menu-item{width:100%;list-style:none;}#responsive-menu-container li.responsive-menu-item a{width:100%;display:block;text-decoration:none;position:relative;}#responsive-menu-container #responsive-menu li.responsive-menu-item a{padding:0 5%;}#responsive-menu-container .responsive-menu-submenu li.responsive-menu-item a{padding:0 5%;}#responsive-menu-container li.responsive-menu-item a .fa{margin-right:15px;}#responsive-menu-container li.responsive-menu-item a .responsive-menu-subarrow{position:absolute;top:0;bottom:0;text-align:center;overflow:hidden;}#responsive-menu-container li.responsive-menu-item a .responsive-menu-subarrow .fa{margin-right:0;}button#responsive-menu-button .responsive-menu-button-icon-inactive{display:none;}button#responsive-menu-button{z-index:99999;display:none;overflow:hidden;outline:none;}button#responsive-menu-button img{max-width:100%;}.responsive-menu-label{display:inline-block;font-weight:600;margin:0 5px;vertical-align:middle;}.responsive-menu-label .responsive-menu-button-text-open{display:none;}.responsive-menu-accessible{display:inline-block;}.responsive-menu-accessible .responsive-menu-box{display:inline-block;vertical-align:middle;}.responsive-menu-label.responsive-menu-label-top,.responsive-menu-label.responsive-menu-label-bottom{display:block;margin:0 auto;}button#responsive-menu-button{padding:0 0;display:inline-block;cursor:pointer;transition-property:opacity,filter;transition-duration:.15s;transition-timing-function:linear;font:inherit;color:inherit;text-transform:none;background-color:transparent;border:0;margin:0;overflow:visible;}.responsive-menu-box{width:25px;height:19px;display:inline-block;position:relative;}.responsive-menu-inner{display:block;top:50%;margin-top:-1.5px;}.responsive-menu-inner,.responsive-menu-inner::before,.responsive-menu-inner::after{width:25px;height:3px;background-color:#003e72;border-radius:4px;position:absolute;transition-property:transform;transition-duration:.15s;transition-timing-function:ease;}.responsive-menu-open .responsive-menu-inner,.responsive-menu-open .responsive-menu-inner::before,.responsive-menu-open .responsive-menu-inner::after{background-color:#0073d0;}button#responsive-menu-button:hover .responsive-menu-inner,button#responsive-menu-button:hover .responsive-menu-inner::before,button#responsive-menu-button:hover .responsive-menu-inner::after,button#responsive-menu-button:hover .responsive-menu-open .responsive-menu-inner,button#responsive-menu-button:hover .responsive-menu-open .responsive-menu-inner::before,button#responsive-menu-button:hover .responsive-menu-open .responsive-menu-inner::after,button#responsive-menu-button:focus .responsive-menu-inner,button#responsive-menu-button:focus .responsive-menu-inner::before,button#responsive-menu-button:focus .responsive-menu-inner::after,button#responsive-menu-button:focus .responsive-menu-open .responsive-menu-inner,button#responsive-menu-button:focus .responsive-menu-open .responsive-menu-inner::before,button#responsive-menu-button:focus .responsive-menu-open .responsive-menu-inner::after{background-color:#0073d0;}.responsive-menu-inner::before,.responsive-menu-inner::after{content:"";display:block;}.responsive-menu-inner::before{top:-8px;}.responsive-menu-inner::after{bottom:-8px;}.responsive-menu-boring .responsive-menu-inner,.responsive-menu-boring .responsive-menu-inner::before,.responsive-menu-boring .responsive-menu-inner::after{transition-property:none;}.responsive-menu-boring.is-active .responsive-menu-inner{transform:rotate(45deg);}.responsive-menu-boring.is-active .responsive-menu-inner::before{top:0;opacity:0;}.responsive-menu-boring.is-active .responsive-menu-inner::after{bottom:0;transform:rotate(-90deg);}button#responsive-menu-button{width:55px;height:55px;position:absolute;top:46px;right:5%;}button#responsive-menu-button .responsive-menu-box{color:#003e72;}.responsive-menu-open button#responsive-menu-button .responsive-menu-box{color:#0073d0;}.responsive-menu-label{color:#003e72;font-size:12px;line-height:13px;}button#responsive-menu-button{display:inline-block;transition:transform .5s,background-color .5s;}#responsive-menu-container{width:75%;left:0;transition:transform .5s;text-align:left;background:#003e71;}#responsive-menu-container #responsive-menu-wrapper{background:#003e71;}#responsive-menu-container #responsive-menu-additional-content{color:#fff;}#responsive-menu-container .responsive-menu-search-box{background:#fff;border:2px solid #dadada;color:#333;}#responsive-menu-container .responsive-menu-search-box:-ms-input-placeholder{color:#c7c7cd;}#responsive-menu-container .responsive-menu-search-box::-webkit-input-placeholder{color:#c7c7cd;}#responsive-menu-container .responsive-menu-search-box:-moz-placeholder{color:#c7c7cd;opacity:1;}#responsive-menu-container .responsive-menu-search-box::-moz-placeholder{color:#c7c7cd;opacity:1;}#responsive-menu-container .responsive-menu-item-link,#responsive-menu-container #responsive-menu-title,#responsive-menu-container .responsive-menu-subarrow{transition:background-color .5s,border-color .5s,color .5s;}#responsive-menu-container #responsive-menu-title{background-color:#fff;color:#fff;font-size:13px;text-align:left;}#responsive-menu-container #responsive-menu-title a{color:#fff;font-size:13px;text-decoration:none;}#responsive-menu-container #responsive-menu-title a:hover{color:#fff;}#responsive-menu-container #responsive-menu-title:hover{background-color:#fff;color:#fff;}#responsive-menu-container #responsive-menu-title:hover a{color:#fff;}#responsive-menu-container #responsive-menu-title #responsive-menu-title-image{display:inline-block;vertical-align:middle;max-width:100%;margin-bottom:15px;}#responsive-menu-container #responsive-menu-title #responsive-menu-title-image img{max-width:100%;}#responsive-menu-container #responsive-menu > li.responsive-menu-item:first-child > a{border-top:1px solid #013968;}#responsive-menu-container #responsive-menu li.responsive-menu-item .responsive-menu-item-link{font-size:15px;}#responsive-menu-container #responsive-menu li.responsive-menu-item a{line-height:50px;border-bottom:1px solid #013968;color:#fff;background-color:#003e72;height:50px;}#responsive-menu-container #responsive-menu li.responsive-menu-item a:hover{color:#fff;background-color:#0073d0;border-color:#297abc;}#responsive-menu-container #responsive-menu li.responsive-menu-item a:hover .responsive-menu-subarrow{color:#fff;border-color:#013968;background-color:#0073d0;}#responsive-menu-container #responsive-menu li.responsive-menu-item a:hover .responsive-menu-subarrow.responsive-menu-subarrow-active{color:#fff;border-color:#013968;background-color:#0073d0;}#responsive-menu-container #responsive-menu li.responsive-menu-item a .responsive-menu-subarrow{right:0;height:50px;line-height:50px;width:50px;color:#fff;border-left:1px solid #013968;background-color:#003e72;}#responsive-menu-container #responsive-menu li.responsive-menu-item a .responsive-menu-subarrow.responsive-menu-subarrow-active{color:#fff;border-color:#013968;background-color:#0073d0;}#responsive-menu-container #responsive-menu li.responsive-menu-item a .responsive-menu-subarrow.responsive-menu-subarrow-active:hover{color:#fff;border-color:#013968;background-color:#0073d0;}#responsive-menu-container #responsive-menu li.responsive-menu-item a .responsive-menu-subarrow:hover{color:#fff;border-color:#013968;background-color:#0073d0;}#responsive-menu-container #responsive-menu li.responsive-menu-current-item > .responsive-menu-item-link{background-color:#0073d0;color:#fff;border-color:#297abc;}#responsive-menu-container #responsive-menu li.responsive-menu-current-item > .responsive-menu-item-link:hover{background-color:#0073d0;color:#fff;border-color:#297abc;}#responsive-menu-container #responsive-menu ul.responsive-menu-submenu li.responsive-menu-item .responsive-menu-item-link{font-size:13px;text-align:left;}#responsive-menu-container #responsive-menu ul.responsive-menu-submenu li.responsive-menu-item a{height:50px;line-height:40px;border-bottom:1px solid #212121;color:#fff;background-color:#212121;}#responsive-menu-container #responsive-menu ul.responsive-menu-submenu li.responsive-menu-item a:hover{color:#fff;background-color:#3f3f3f;border-color:#212121;}#responsive-menu-container #responsive-menu ul.responsive-menu-submenu li.responsive-menu-item a:hover .responsive-menu-subarrow{color:#fff;border-color:#3f3f3f;background-color:#3f3f3f;}#responsive-menu-container #responsive-menu ul.responsive-menu-submenu li.responsive-menu-item a:hover .responsive-menu-subarrow.responsive-menu-subarrow-active{color:#fff;border-color:#3f3f3f;background-color:#3f3f3f;}#responsive-menu-container #responsive-menu ul.responsive-menu-submenu li.responsive-menu-item a .responsive-menu-subarrow{left:unset;right:0;height:40px;line-height:40px;width:40px;color:#fff;border-left:1px solid #212121 !important;border-right:unset !important;background-color:#212121;}#responsive-menu-container #responsive-menu ul.responsive-menu-submenu li.responsive-menu-item a .responsive-menu-subarrow.responsive-menu-subarrow-active{color:#fff;border-color:#212121;background-color:#212121;}#responsive-menu-container #responsive-menu ul.responsive-menu-submenu li.responsive-menu-item a .responsive-menu-subarrow.responsive-menu-subarrow-active:hover{color:#fff;border-color:#3f3f3f;background-color:#3f3f3f;}#responsive-menu-container #responsive-menu ul.responsive-menu-submenu li.responsive-menu-item a .responsive-menu-subarrow:hover{color:#fff;border-color:#3f3f3f;background-color:#3f3f3f;}#responsive-menu-container #responsive-menu ul.responsive-menu-submenu li.responsive-menu-current-item > .responsive-menu-item-link{background-color:#212121;color:#fff;border-color:#212121;}#responsive-menu-container #responsive-menu ul.responsive-menu-submenu li.responsive-menu-current-item > .responsive-menu-item-link:hover{background-color:#3f3f3f;color:#fff;border-color:#3f3f3f;}}.single-post p{font-size:16px;}.single-post #genesis-content ul li,.single-post #genesis-content ol li{font-size:16px;line-height:1.6;margin-bottom:15px;}#form-left p,#form-left ul li,#form-left ol li{font-size:16px;}h2 span{font-weight:600 !important;}.post-edit-link{display:none;}#small-form-cont{margin-top:0;}template#MDow-1 ~ div{visibility:hidden;}

Footer