Upload Policy Documents

Document Upload Step 1 of 2

Please provide your name and phone number below to ensure American Health and Life Insurance Company and/or Triton Insurance Company may contact you with any questions. * Are required fields

Member Number:*

Claim Number:

Insured First Name:*

Insured Last Name:*

Postal Code:*

Phone Number:*

Email:*

I am submitting this form for the insured

Relationship to the Insured:*

First Name:*

Last Name:*

Phone Number:*

Document Upload Step 2 of 2

For a successful upload, please use the following file types: PDF, JPG, TIF, or PNG. The document cannot exceed 10mb.

(Please Note: If you are using a Mobile Device, the “Take a Photo” option in the Choose File cannot be used at this time.)

Document 1

Document 2

Document 3

Document 4

Document 5

You may include information about your files below:

I have read and understand the agreement

(Required to proceed)

Agreement for Submission of Personal Information via Electronic Communication

With your acceptance of this Agreement you are Acknowledging that you are knowingly submitting documents that contain Personal Information through electronic means. We make best efforts to protect all confidential information and process these communications through secure and protected systems.

Communications

You are not required to choose electronic communications, and use of this electronic communication process does not require you to use this process for future correspondence. You also have the option to submit documents to us in paper form via fax or mail, at your discretion.

Our receipt of your information through electronic communications does not prevent us from communicating with you or sending documents to you in paper form at our discretion. We may also require that you provide certain communications to us in non electronic form.

Note: It is your responsibility to maintain copies of all documentation submitted to us whether submitted electronically or in paper format.

Future Submissions

This Agreement only applies to this current submission of documents. Any future electronic submissions will also require your Acknowledgment of this Agreement.

Your Contact Information

It is your responsibility to promptly inform us of changes to your contact information.

Our Contact Information

If you need assistance, please contact us at 844-859-5323. between the hours of 7:00 AM - 7:00 PM Central Time, Monday through Friday.