Opt-In Form

Notice of Intent to Opt In Form

Use this screen to access and electronically sign your Notice of Intent to Opt In Form. Enter your Date of Birth and the last four digits of your Social Security Number and then click Sign Opt In Form.

Date of Birth:

Last Four Digits of the Social Security Number:

Check this box to let us know you're a human.
(You only have to do this once.)

Sign Opt In Form

If you have issues accessing the Form, you may contact the Claims Administrator by phone, 1-888-724-0247, or email, ClaimsAdministrator@BrownGreerJFM.com, for assistance. Direct all other questions to your lawyer.