Claims & Requests

Call us for help with claims and requests.

Coverage cannot be bound or altered online. Complete the form below to have a service representative contact you to finalize your request.

Type of Inquiry *

First and Last Name *

Email Address *

City and State *

Phone *

Can we send you text / SMS messages?

By selecting 'Yes' you consent to receive text / SMS messages from Leavitt Select Insurance Services. Privacy Policy

Employer Name

Member Number

Comments *

County

Please note: Claims and change requests cannot be completed online. A service representative will need to contact you to finalize your request.