File A Claim

Accidental Damage

If your hearing instrument is accidentally damaged, complete this claim form in its entirety and return it to Midwest Hearing Industries with the damaged hearing instrument. The hearing instrument should be packaged securely and insured through the postal services.

Lost Hearing Instrument

Claim Form

If your hearing instrument is lost or damaged beyond repair, complete this claim form in its entirety and return it to Midwest Hearing Industries. In the event of an in the ear instrument, an ear impression must be sent with the claim form to Midwest Hearing Industries (unless there is a laser scan on file with the manufacturer).

The manufacturer will repair or replace your hearing instrument and return it to your dispensing office/clinic and Midwest Hearing Industries will make payment direct to the manufacturer for the repair or replacement. All incidental charges by that dispensing office/clinic for hearing test, ear impressions, or other services will be your responsibility.

Claim Type

Name:

Address:

City:

State:

Zip/Postal Code: (ex. 55425)

Phone: (ex. 123-456-7890)

E-mail Address: (ex. user@domain.com)

Policy Number:

Manufacturer:

Model:

Serial Number:

    

Color:

Laser scan on file?:

  

Date of Loss/Damage: (ex. MM-DD-YYYY)

Location of Loss/Damage:

Describe Exactly How Loss or Damage Occurred In Detail (How, When & Where):

I certify that the above statement is true.

Insured's Signature: __________________________________________________ ____________________________

Return my hearing instrument to my Dispenser as listed below:

Name:

Address (no P.O. Boxes please):

City:

State:

Zip/Postal Code: (ex. 55425)

Phone:

Denotes required fields

Please mail your completed claim form to the address below:

Midwest Hearing Industries, Inc.
4510 West 77th Street, Suite 109
Minneapolis, MN 55435

Phone: 1-800-821-5471
Fax: 952-835-9481