• Hearing Loss Insurance Claim Form

    Use this form to submit a hearing loss insurance claim with your policy details, medical information, and supporting documents.

  • Claimant Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Policy and Insured Information

  • Claimant Relationship to Policy*

  • Hearing Loss Claim Details

  • Date hearing loss was first noticed*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Onset pattern*
  • Ear affected*
  • Primary symptoms experienced*
  • Date of related accident or event
     - -
    2 digit month, 2 digit day, 4 digit year

  • Medical Evaluation and Treatment

  • Date of First Medical Evaluation*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Hearing Aid Recommendation or Fitting Status*
  • Additional Follow-up Care Planned*

  • Supporting Documentation

  • Upload a File
    Drag and drop files here
    Choose a file
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  • Upload a File
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    Choose a file
    Cancelof
  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof
  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof
  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof

  • Claim Submission Details

  • Claim submission date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Preferred contact method for claim updates*
  • Should be Empty:
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