In the final step, you will be asked to attach documentation relevant to your claim.
View this guide to help determine what documents you need to submit:
Optional information that may be necessary to complete your claim:
If you get stuck at any point, give us a call 800-690-6295 (toll free) or 317-818-2808 (collect).
Complete for payment through bank transfer outside the U.S.
General: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act. Alaska: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law. Arizona: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. Arkansas, Louisiana, Maryland, West Virginia: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. California: For your protection California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Connecticut: This form must be completed in its entirety. Any person who intentionally misrepresents or intentionally fails to disclose any material fact related to a claimed injury may be guilty of a felony. Delaware, Idaho, Indiana: Any person who knowingly, and with intent to injure, defraud, or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony. District of Columbia: Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree. Hawaii: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Maine: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or a denial of insurance benefits. Michigan, North Dakota, South Dakota: Any person who knowingly and with intent to defraud any insurance company or another person files a statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and subjects the person to criminal and civil penalties. Minnesota; A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. Nevada: Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may be guilty of a criminal act punishable under state or federal law, or both, and may be subject to civil penalties. New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud as provided in section 638:20. New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. New Mexico: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime , and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim foe each such violation. Ohio: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Oklahoma: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Oregon: Any person who makes an intentional misstatement that is material to the risk may be found guilty of insurance fraud by a court of law. Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Tennessee, Virginia, Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purposes of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. Texas: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
I hereby authorize Seven Corners, Inc. (hereinafter COMPANY) to mail any payments to the above listed address and to deposit any amounts owed me for reimbursement of medical expenses or services rendered by initiating credit entries to my account at the financial institution (hereby BANK) indicated above. Further, I authorize BANK to accept and to credit any credit entries indicated by COMPANY to my account. In the event that COMPANY erroneously deposits funds in my account (by way of example, I am not entitled to the funds or the amount of deposit Is incorrect or such funds are deposited in the wrong account), I authorize COMPANY to debit or credit my account in the amount necessary to correct the initial deposit, but in no case shall any debit exceed the amount of the initial deposit. I further agree COMPANY is not responsible for any transaction fees charged and will release Seven Corners of any liability in the event of lost or stolen payments.
Seven Corners Inc. Privacy Notice
Seven Corners Inc. (referred to in this notice as “Seven Corners, “we” and/or “us”) considers privacy with the utmost of seriousness. We respect and are committed to protecting the privacy of visitors and users of our websites and services. We collect, use, disclose and otherwise process personal information in accordance with applicable privacy/data protection laws.
This notice explains how and why we collect, use and disclose personal information, whether in oral, electronic or written form, of individuals who interact with Seven Corners. It also explains how we safeguard the information you provide to us directly or indirectly.
This privacy notice also covers the www.SevenCorners.com family of Web sites, available to visitors located throughout the world. These Web sites are operated in the United States in accordance with laws of the United States and visitors to our Web sites should be aware that the laws of the United States may differ from those of your country of residence.
Seven Corners reserves the right to change the Privacy Policies and Practices at any time. We will post changes on this Web site, which will take effect once posted.
Collection of Personal Information
We collect personal information in a variety of ways, including our Web sites and the internet, over the telephone, through correspondence and from other sources, and, through third parties who have authority to disclose personal information to us, or where we are required to do so by law. The personal information collected by us shall be limited to those details necessary for the purposes identified to you and necessary for business purposes with respect to our products, services and other business relationships involving you.
Typically, we will explain the purpose the collection and use of the personal information when we request it. If you decide to withhold particular information, it may limit our ability to provide you with the services or products you requested.
The Seven Corners family of websites is not targeted to and does not intentionally collect personal information from children under the age of 18. If we discover that a child has provided us with personal information online through this Web site, we will take reasonable steps to delete this information. If you believe we may have received personal information from a child under the age of 18, please contact us at firstname.lastname@example.org.
We may use “cookies” to help us improve our Web site by tracking your navigation habits and to store some of your preferences. A cookie is a small file created by an Internet site to store information on your computer. Cookies do not allow Web sites to gain access to other information on your computer. Once a cookie is saved on your computer, only the Web site that created the cookie can read it. No cookie placed on your computer will contain personal information unless it is encrypted.
Use and Disclosure of Personal Information
We will not sell your Personal Information to anyone. We may disclose any of your Personal Information, within acceptable regulatory limitations, when it is necessary for the conduct of our business, or where disclosure is required by law.
In the event we disclose personal information to our service providers, we require our service providers to agree to contractual requirements that are consistent with our privacy and security policies and legal requirements. Service providers are required to use the personal information only for the specific purpose for which we supply it to them, and otherwise comply with legal requirements applicable to the personal information in question. If you believe that a third party has disclosed your personal information to us without your consent to do so, please contact that third party. If they do not respond adequately to your inquiries, please contact us at Privacy@sevencorners.com.
While we do not utilize member personal information to send unsolicited marketing materials, please note that we may send certain information to you for legal, regulatory, or ethical purposes.
Storage of Personal Information
The personal information that we collect from you may be transferred to and will be stored in the United States. The United States may have different levels of privacy protection than apply in your country of residence. By submitting your personal information via our Web site, you agree to any such transfers, storage or other processing. We will take all steps reasonably necessary to ensure that your personal information is handled securely and in accordance with this privacy notice.
It is important to note that some or all of your personal information you provide to third party service providers (such as doctors and hospitals) may be held by them in countries other than your own. Your personal information will be subject to the applicable laws of each such jurisdiction, which may not provide for the same protection as your country of residence. Seven Corners cannot be held responsible for the practices of those third party service providers.
Security of Personal Information
We utilize industry standard security safeguards, including maintaining physical, electronic, and procedural safeguards, in compliance with applicable laws to protect personal information from loss and unauthorized access, modification, disclosure, inappropriate alteration or misuse.
Employees are trained on the importance of privacy including prohibiting the disclosure of any customer information to unauthorized individuals or parties.
Electronic customer files are kept in a highly secure environment with restricted access within a secure building. Paper-based files are stored in a secure building and are further restricted by locking filing cabinets. Access is restricted to authorized employees who have a legitimate business purpose and reason for accessing your personal information.
To guard against unauthorized access, you are required to sign-on to your accounts and secured areas of the Seven Corners websites using a User ID and a password. Both the User ID and password are encrypted when sent over the internet. You are responsible for protecting your own information. Do not share your User ID or password with anyone. If you suspect that someone is using your User ID or password, please report it immediately by sending an e-mail to privacy@SevenCorners.com. Always logout of our Web site to keep your information and account secure. Protect your computer and environment with virus protection and other safeguards to make sure others cannot access your information through your computer. Seven Corners will not be liable for disclosures of your personal information due to errors in transmission or unauthorized acts of third parties.
When you call us for patient and specific product questions, you will be required to verify your identity by providing personal information. We will only use this information in order to identify you.
While we take reasonable steps to protect personal information transmitted electronically as outlined in this notice, we cannot guarantee our ability to do so as no internet transmission is 100% secure.
Access and Accuracy
Where allowed by law, you may request access to personal information we store about you by sending an e-mail to email@example.com.
There may be circumstances when we are unable to provide access to your personal information. We may deny, or restrict access for legally permissible reasons, such as situations when the information contains references to other individuals and is not reasonably severable, or when it cannot be disclosed for legal, security, or commercial proprietary reasons. In the case that the access may be unreasonably burdensome or expensive, the access may be denied or we may charge a fee. We will advise you of any reason for denying or restricting an access request.
We shall make every reasonable effort to ensure your personal information is accurate, complete and up-to-date. If you believe that we have inaccurate, incomplete or out-of-date personal information about you, you may ask us at any time to correct that information. When an individual successfully demonstrates the inaccuracy or incompleteness of personal information held by us, we will correct or update the information as required.
Please note that before we are able to provide you with any information or correct any inaccuracies we may ask you to verify your identity and to provide other details to help us to respond to your request. We will only use this information in order to verify your identity. Where appropriate, we will communicate these changes to other parties who may have received incorrect information from us.
Additionally, certain business partners may require that you contact them to correct your personal information; in this case we will notify you and provide the appropriate contact information.
In the course of daily operations, access to personal information is restricted to authorized employees who have a legitimate business purpose and reason for accessing it.
We securely destroy, erase or de-identify personal information when it is no longer required to fulfill our services and commitments to you or our contractual obligations following applicable business, legal, or regulatory requirements.
Links to other websites
When we think that information might be of interest or us to our members, we may provide links to other Web sites, not owned or controlled by Seven Corners. A link to a non-Seven Corners Web site does not constitute or imply endorsement by Seven Corners; we cannot guarantee the quality or accuracy of information presented on non-Seven Corners Web sites. Additionally, we cannot be responsible for the privacy practices of other sites. We encourage you to review the privacy practices of any Web site you visit.
Court Order Protection Request
To submit a valid court order of protection and/or a request to receive communications of claim-related information by alternative means or at alternative locations to Seven Corners, Inc., please send the following information to Seven Corners, Inc.
1. policy information if available;
2. any alternative address, telephone number or other method of contact; and
3. a valid court order of protection issued by a New York State Court and/or a statement that disclosure of claim-related information could endanger the person seeking confidentiality.
The information may be sent to the following office address or the email address:
Seven Corners, Inc.
303 Congressional Boulevard
Carmel, IN 46032
ATTN: PRIVACY OFFICER
Recommended subject line: Confidentiality Request
To revoke a request, a sworn statement that confidentiality is no longer necessary is required.
You will be asked to attach proof of expenses and other needed documents in the next step.
An email is on its way as we speak from firstname.lastname@example.org confirming receipt of your online claim. The email will include your claim number as well as some additional details about your claim. My team will be in touch with you regarding your claim in the next 5-7 days upon review of your claim. Until then, enjoy the rest of your day and rest easy knowing you’ve done the hard part and we’ll take it from here. My team is looking forward to bringing your claim to a speedy resolution.
To check the status of your claim, you can log into your Seven Corners account, or register a new one if you do not have one. Go to My Account »
If you have questions, please email email@example.com or call us at 800-690-6295 (toll free) or 317-828-2808 (collect). Please know that we will do our best to process your claim quickly and accurately.
Thank you for being a valued customer,
Claims Manager at Seven Corners