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Consolidated Health Plan Insurance Service
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Welcome to CHP
Phone 1-800-525-8669
Fax 1-413-214-7761
Claims 1-800-237-2917
 
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Online Claim Form  
*fields are mandatory
This is for notice/record only: (what's this?)

Preparer
           
* Title:  
* First name: * Last name:
  Company name (if applicable):        
Address: City:
     
State: Zip:
* Phone number:   Type:  
  Phone number:   Type:  
  Phone number:   Type:  
* E-mail:
  

Insured Information
           
       
* Title:  
* First name: * Last name:
  Company/organization/club name
(if applicable): 		       
* Address: * City:
     
* State: Zip:
* Phone number:   Type:  
  Phone number:   Type:  
  Phone number:   Type:  
E-mail:
  

Agent Information
           
       
  Agency name:        
Contact first name: Contact last name:
Address: City:
     
State: Zip:
Phone number:   Type:  
  Phone number:   Type:  
  Phone number:   Type:  
E-mail:
  


Loss Information
   
* Describe the loss and what happened. Include any injuries or property damaged or stolen.
 
* Date of loss: Pick a date Policy number:  
         
Loss Location
 
 
*Street address (no PO box):   *City:  
    *State:  
  Zip:  
       


Additional Information
         
Details/comments: