Dentists Benefits
Insurance Company
10505 SE 17th Ave
Milwaukie, OR 97222
503-765-3510
800-452-0504 toll free
503-765-3511 fax

Claim Form

Name Of Insured:
Policy Number:
Address:
Phone:
Bus. Phone:
Date Loss Occurred:
Time of Loss:
Address Where Loss Occurred:
Type of Claim:
Were the Police Notified:	Yes No
Police Report Number:
Anyone Injured:	Yes No
If yes, was first aid given?	Yes No
Name of Hospital:
Attending Physician:
Address:
Phone:
Description of Injury or Accident:
Property Damaged (Give Model #, Serial #, Estimated Value, and Description of Damage for each item:
Additional Comments: