Critical Illness Insurance Claim Form
1. Policyholder Information
Policy Number
Full Name
Date of Birth
Address
Phone
Email
2. Patient Information
Patient Name
Relationship to Policyholder
Patient Date of Birth
3. Illness / Diagnosis Details
Name of Critical Illness
Date of Diagnosis
Attending Doctor Name
Name of Hospital / Clinic
Brief Description of Symptoms
4. Documentation Checklist
Medical Report
Diagnosis Certificate
ID Proof
Other Relevant Documents
5. Declaration and Signature
Declaration
Signature
Date