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Injury & Illness Claim Form

To submit an injury or illness (disability) claim, complete the form below, or you can stop by any branch location or call us at 888.213.2848. To be eligible for coverage, you must have an active Injury & Illness policy on your American 1 loan and are excused from work by a doctor for at least 14 days.

* Required Fields

Today's Date:

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Account Number:

First day unable to work as determined by physician:

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Full Name:

Phone Number (Including area code):

Email:

Address :

City:

State:

ZIP:

Date of Birth:

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Security Code: