Claim Form
Please review the following instructions before proceeding:
1. After submission, you will receive a summary of your cover for review.
2. The next step involves submitting the details of your claim. Please provide a brief description of the accident and circumstances.
3. For damaged glasses, please upload four (4) photos of the damaged glasses, along with a copy of your prescription and the original receipt from when the glasses were purchased
4. For stolen glasses (theft), please upload the police report, along with a copy of your prescription and the original receipt from when the glasses were purchased.
Policy Number
First Name
Last Name
Policy submitted successfully.
Please wait while the Policy Certificate and the Policy Disclosure Statement (PDS) being emailed to the patient.
