Michigan Millers Insurance - Submit A Claim

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Michigan Millers Home / Claims / Claim Options / Submit a Claim

Submit A Claim

Insured Information

Name*

Policy Number*

Street Address*

City* State* Zip*

Contact Information

Name*

Email*

Phone*
() -

Alternate Phone
() -

Loss Description*

Date of Loss*

Claimant Information

Name*

Date of Birth

SSN*

Phone*
() -

Last Day Worked
Claimant is still off Work

Street Address*

City*

State*

Zip*

Type of Injury*

Accident Location

City*

State*

Zip*

Physician or Healthcare Provider

Name
Street Address
City	State	Zip

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