Claims: If you have a claim from the insolvency of Bedivere Insurance Company, American Country Insurance Service, or American Insurance Services, please complete the statement of Claim with the Auto-Personal Injury Protection (PIP) and/or Workers Compensation (WC) forms listed under Claim Information.

Forms

The following forms require Adobe Reader. Please download and complete the form pertaining to your loss in its entirety.

Mail the completed form to:

MPCGA
PO Box 531266
Livonia, MI 48153-1266

AC Script

AC_Script_Request_r2

Attendant Care Form

Attendant_Care_r2

Authorization of Release of Records

Authorization_of_Release_of_Records_r2

Auto - Personal Injury Protection (PIP)

PIP_Form_v2

Mileage Reimbursement Form

Mileage_Reimbursement_r2

Prescription Reimbursement Form

Prescription_Reimbursement_r2

Replacement Services Form

Replacement_Services_r2

Statement of Claim

Statement_of_Claim_v2

Workers Compensation (WC)

Web_-_Initial_WC_PEO_Questionnaire_with_Affidavits_REVISED_r2

Form W9

fw9_2018-1