Notice of Loss

This Notice of Loss form should be submitted within 20 days of an "Accident or Injury" as defined in the Policy.

Fields marked in bold are required.

Name of Injured Person:
Policy (or Certificate of Insurance) Number:
Email address of Injured Person:
Confirm Email address:
Phone Number of Injured Person:
(or authorized representative)
Date of Accident: Calendar
Time of Accident:
Place of Accident:
For example: Wasatch Cache National Forest, Little Cottonwood Canyon, Mt Superior
Was the injured person evacuated/rescued: Yes | No
Were ground or air ambulance services used: Yes | No
Medical Treatment Facility:
For example: University of Utah Medical Center, Emergency Department

You will receive a Proof of Loss form via email. If you do not receive a Proof of Loss form within 15 days, please call us at (800) 574-7117 or simply click on the CLAIMS page and select the "Proof of Loss" form from the menu.