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Coulee Bank

To report a claim or request a benefit activation, select the form that best describes your situation.
Follow the instructions and complete the required fields to ensure timely processing.
If you need assistance in identifying the correct form or assistance in completing a form, please call the Pekin Insurance Financial Products Benefits Center at 1-800-322-1060, Extension 2521.

Benefit Activation Request – Accidental Death   CL 1009
Benefit Activation Request – Death   CL 1010
Benefit Activation Request – Involuntary Unemployment   CL 1013
Benefit Activation Request – 14 Day Disability   1015-14R-25 HRS (11-07)
Benefit Activation Request – 30 Day Disability   CL 1015-2
Benefit Activation Request – Hospitalization   CL 1019

Call Toll-Free 1-800-322-0160