Upload Involuntary Unemployment Insurance Claims Documents

Document Upload Step 1 of 2

Please provide your name and phone number below to ensure OneMain Solutions may contact you with any questions. * Are required fields

Policy Account Number:*

Claim Number:

Insured First Name:*

Insured Last Name:*

Insured Date of Birth:*

Last 4 digits of Insured’s Social Security Number:*

XXX - XX -

Zip/Postal Code:*

Phone Number:*

Email:*

Last Date Employed:

Date of Hire:

Hours Working Per Week:

(prior to job loss)

Full or Part Time?

Have you experienced previous interruption(s) in employment of 30 days or more in the last 12 months?*

Yes No

Employers Company Name:*

Employers Phone Number:*

Reason for Unemployment:*

Other reason:

If returned to work, what day?:

Hours Working Per Week:

Date Registered with the State Employment Office:

Note: You must register with your state to be considered for Triton insurance benefits.

Have you received your first state unemployment benefit check?*

Yes No

Date of first state unemployment benefit check:*

Date of most recent state unemployment benefit check:*

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 10 MB.

Upload State Unemployment Benefit or Registration Document(s) here:

Upload Additional Documents:

You may include information about your files below:

I have read and understand the required Attestations to file a Claim*

I have read and understand the Agreement*

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 800-307-0048 between the hours of 8:00 AM - 8:00 PM Eastern Time, Monday through Friday.

CLAIM FORM REQUIRED ATTESTATIONS FOR INVOLUNTARY UNEMPLOYMENT INSURANCE (IUI) CLAIMS

STATE NOTICES/WARNINGS:

For Arizona residents only:

For your protection Arizona law requires the following statement to appear on the form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

For California residents only: For your protection California law requires the following to appear on the form. 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.

For New York residents only:

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 state value of the claim for each such violation.

For Pennsylvania residents only:

Any person who, with the intent to defraud, knowingly submits an application to or files a claim with an insurance company or other person containing false, incomplete, misleading or deceptive facts, statements or information may be guilty of insurance fraud which is a crime and subjects such person to civil and criminal penalties that can include fines and confinement in prison.

For residents of other states (NOTE: None of these notices apply to Oregon residents):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.

I confirm that I have read the above applicable State Notice/Warnings.*

I confirm that the information I have provided herein is accurate and complete.*