Claim Form

Instructions

  1. Complete all the information required on the claim form
    *Claim form must be submitted to RPS Bollinger within 1 year of the injury date.
  2. Once complete, print out the pre-filled claim form
  3. Have an authorized official sign the claim form
  4. Mail, email or fax the claim form to RPS Bollinger




Claim Status

To check the status of an Accident Claim, please complete our online form.

Blank Claim Form

If you would like a blank claim form, please select your accident date below and then press “Print Blank Claim Form”.

  • *Accident Date