If emergency surgery is required, immediate notice is required. All other requests will be denied if not submitted within one week from the date of the incident*.
By clicking "Send" under penalty of perjury, you swear and affirm that the foregoing facts are true and correct. Should any of the information that you submit be false, you understand any request for reimbursement may be denied.
(*exceptions may be made only in extreme, extenuating circumstances, like an act of God or acute, personal hardship that interfere with the ability to submit an incident form).
1035 State Rd 7 Suite 215
Wellington, Florida 33414
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