Sample Claim Forms

The Fund is providing the SAMPLE Claim Forms below to assist you in preparing materials for filing your claim. Please note that these documents are strictly samples and should not be completed and submitted to the Fund in place of an electronic or hardcopy claim form. If you have any questions, or would like to request a hardcopy claim form, please call our toll-free number 1-855-885-1555 (or 1-855-885-1558 for the hearing impaired).

Personal Injury Claimants

Deceased Individuals