Critical Illness Claim Form

This form lets a policyholder notify their insurer of a critical illness diagnosis and submit the details needed to process a benefit payout.

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Section

Full Name

Nombre

Apellido

Employer Name

Email

Phone Number

Date of Birth

Gender

Male Female Other

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Section

Same as Section 1 (If you check this box, you do not need to complete this section — skip to Section 3)

Yes No

Spouse / Child

Patient Name

Nombre

Apellido

Email

Phone Number

Date of Birth

Gender

Male Female Other

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Section

Please select the condition that applies to your claim

If the claimant is deceased, select and provide a copy of the death certificate

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