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Claims History Request from an Employee No Longer Insured by CRICO

Please complete this form. Upon submission, you will be directed to the payment page where you can remit the $25 claims history processing fee using PayPal.
* = required field

Requirements for Claims History Requests

Delivery & Support Information

Confirmation and Follow-Up

By checking the box, you are confirming that you are the former CRICO-insured provider. Further, you acknowledge that you have verified the recipient email address above.