Report an Event for a Clozure Member

If you are a Legacy Contact named by a Clozure member, use this page to report that the member is incapacitated or has died. We will verify your request and send you the information the member chose to share at this first stage. First responders and medical professionals can also request the member's emergency information: see the box at the bottom of the form.

If someone is in immediate danger, call 911 first. This form is not monitored in real time and is not an emergency service.

How it works

Tell us what happened. Choose Incapacitated or Death, and enter the member's membership number and last name.
Identify yourself. Enter your name, phone number and email address. For a Legacy Contact, these must match the details the member gave us. First responders and medical professionals check the box at the bottom of the form and give their agency or facility details instead.
We verify. We check your details against the member's record. The checks differ by type of report and requester (see below).
You receive the information by email. If verification passes, we email a secure link to the information the member authorized for release at this stage, typically emergency medical information for hospital or care staff. Wills, legal documents and financial records are not part of this stage.

What happens for each type of report

Incapacitated: The member cannot speak or make decisions for themselves, for example because of an accident, a sudden illness or another medical emergency. After verification, we send a secure link to the member's emergency medical information (for example conditions, medications, allergies and physician details) so it can be passed to hospital or EMS staff. We may call you at the number provided to confirm details.

Death: Handled with extra care. We will contact you to confirm the event and may ask for supporting documentation, such as a death certificate or obituary, before releasing anything. Release of additional documents follows the member's own instructions and is not covered by this form.

First responders and medical professionals: If you are not a Legacy Contact, you can request the information the member designated for first responders and medical professionals. Your request is verified before anything is sent, which may include a call-back to your agency or facility's main number, so please keep a phone available. Requests are logged and attributed to you.

For your protection and the member's, we do not tell anyone whether a specific membership exists. If your details do not match, you will see the same confirmation message as everyone else, and nothing will be released.

1. What are you reporting?

IncapacitatedUnable to speak or decide for themselves DeathThe member has passed away

Where is the member now? (hospital or location, if known) Date it happened

Date of death City and state where the death occurred (optional) Death certificate or other proof (optional now, but speeds up verification. PDF, JPG or PNG, up to 10 MB. A funeral home letter or published obituary may also be accepted.)

Uploaded documents are stored securely, used only to verify this report, and are not shared with anyone else.

We are sorry for your loss. A member of our team will reach out to you directly to complete verification.

2. The member

Membership number

Member's last name

3. About you (the reporter) Your full name

Phone number

Email address (the secure link is sent here)

Your relationship to the member (optional)

Anything else we should know? (optional, please do not include medical details here)

I confirm that I am the Legacy Contact named by this member, that the information above is true, and I understand that providing false information to obtain someone's personal or medical information may have legal consequences. I agree to be contacted at the phone number and email above regarding this report.

I am a first responder or medical professional requesting this member's emergency information in place of a Legacy Contact.

Your professional details

Please use your official agency or facility email address in section 3. We verify these details before any information is released.

Your role Agency or facility name

Badge, license or NPI number

Agency or facility main phone (we may call back to verify)

Incident or case number (optional; please do not enter patient details) I confirm that I am a first responder or licensed medical professional, that I am requesting this information solely to provide emergency care or perform my official duties for this member, and that the information above is true. I understand that my request will be verified and logged, and that false statements may have legal consequences.

If you're having trouble, call 1-844-256-9873

Reports are logged. Information released is limited to what the member authorized in advance.