Quick-Pay Claims Transmittal


PO Box 530
Minneapolis, MN 55440-0530
Toll Free: (877)663-7464

Quick-Pay Claims Transmittal
Email: claims@aclcares.com
Fax: (952) 556-8145

Funeral Home Name:  
Funeral Home Address:      
Telephone Number:  
Funeral Home Contact:  
Deceased’s Name:  
Policy Number:  
Date of Death:  

 

All States Except FL and TN
Claims process will begin upon receipt of a Quick Pay Claims Transmittal form. A death certificate is not required prior to payment but
must be received to close the file.

FL and TN
Claims will be processed immediately upon receipt of a Quick Pay Claims Transmittal form and a statement of the current at-need
funeral price. A death certificate is not required prior to payment but must be received to close the file.

All States
Claims on Preferred policies less than two years old require a Quick Pay Claims Transmittal form, death certificate, and a Claimant’s
Statement (Form PN 9 1-1-2008) before the claims process can begin.
Please note: Fraud Warnings on Reverse side. Keep a copy for your records only. The Fraud Warning does not
need to be faxed with this side of claim form.


Form PN-4 (08/01/2023)

Fraud Warnings


WARNING: 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 may be guilty of a crime and subject to fines, confinement In prison and/or denial of Insurance benefits. This warning applies to the following states: Alabama, Alaska, Arkansas, Connecticut, Delaware, Hawaii, Idaho, Illinois, Indiana, Iowa, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, Rhode Island, South Carolina, South Dakota, Texas, Utah, Vermont, Virginia, West Virginia, Wisconsin, Wyoming.
ARIZONA WARNING: 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.
CALIFORNIA WARNING: For your protecllon California law requires the following to appear on this form: 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.
COLORADO WARNING: WARNING: 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 damage. Any insurance company or agent of an Insurance company who knowingly provides false, incomplete, or misleading facts or lnformatlon 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 lo the Colorado division of insurance within the Department of Regulatory Agencies.
DISTRICT OF.COLUMBIA WARNING: 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 lo a claim was provided by the applicant.
FLORIDA WARNING: WARNING: 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.
GEORGIA WARNING: WARNING: Any person who knowingly and with Intent to defraud any Insurance company or other person files an application for insurance or a statement of claim containing any materlally false information, or, for the purpose of misleading, conceals Information concerning any fact material thereto, commits a rraudulenl insurance act, which Is a crime and subjects SUI* person to criminal and civil penalties.
KANSAS WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit, or knowingly presenls false information In an application for insurance may be gullly of fraud, as delermlned by a court of law, and subject to fines, confinement in prison and/or denial of Insurance benefits.
KENTUCKY WARNING: WARNING: Any person who knowingly and with intent to defraud any Insurance company or other person files a slatement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commtts a fraudulent Insurance act, which is a crime.
LOUISIANA WARNING: 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 may be guilty of a crime and subject to fines; and confinement in prison.
MAINE WARNING: 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.
MARYLAND WARNING: WARNING: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false lnfonmation in an application for insurance is gullty of a crime and may be subject to fines and confinement in prison.
NEW HAMPSHIRE WARNING: WARNING: 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 RSA 638:20.
NEW JERSEY WARNING: Any person who knowingly files a statement of claim containing any false or misleading Information is subject to criminal and civil penallles.
NEW YORK WARNING: 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, i,nformation 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 $5,000
and the stated value of the claim for each such violation.
OREGON WARNING: WARNING: Any person who knowingly and with intent to defraud or solicit another to defraud an Insurer by submitting an application, or by filing a claim containing a false statement as to any material fact, may be violating state law.
PENNSYLVANIA WARNING: WARNING: Any person who knowingly and with Intent to defraud any insurance compa,ny 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 WARNING: WARNING: II ls a crime to knowingly supply false, incomplete, or misleading Information to :an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.
WASHINGTON WARNING: WARNING: It is a crime to knowingly provide false, Incomplete, or misleading information' to an insurance company·for the purpose of defrauding the company. Penalties Include imprisonment, fines, and denlal of insurance benefits.

I hereby certify that, to the best of my knowledge, the information provided above is true.

Funeral Home Representative:                                                                                                                                                                                             Date[esigtodaydate name="esig-sif-today-1701358473376" verifysigner="undefi

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Document name: Quick-Pay Claims Transmittal
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January 23, 2024 10:16 am CDTQuick-Pay Claims Transmittal Uploaded by John kohrs - kohrsj@driasi.com IP 136.228.217.166
March 8, 2024 12:46 pm CDTWanda Becker - BeckerW@driasi.com added by John kohrs - kohrsj@driasi.com as a CC'd Recipient Ip: 136.228.217.166
March 8, 2024 12:46 pm CDTBarb Mayer - MayerB@driasi.com added by John kohrs - kohrsj@driasi.com as a CC'd Recipient Ip: 136.228.217.166
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