Forms / Applications

Claims Status Request


Claims Status Request Form
Named Insured:
Claim Number:
DOL:
Line of Business:
Info Requested:

If you are not the current broker-of-record we require an authorization signed by the named insured to release this information to you. Please print this screen and fax it with the written authorization to 212-297-3131; Attention: Claims Status Update Request, or email it to DPGClaims@distinguished.com.

Agent/ Broker Requesting Info
Name:
Company:
Phone #:
Fax#:
Email:

The Distinguished Programs Group
6 East 43rd Street, New York, NY 10017
1-212-297-3100