Terminal Illness Insurance Claim Form
1. Policyholder Information
Full Name
Date of Birth
Policy Number
Contact Number
Address
2. Illness Details
Diagnosis
Date Diagnosed
Expected Life Expectancy
Attending Physician's Name
Hospital/Clinic Name
3. Payment Details
Preferred Payment Method
Bank Transfer
Cheque
Other
Bank Account Details
4. Supporting Documents
Attach Medical Reports/Certificates
5. Declaration & Consent
I hereby declare that the information provided is true and complete. I give consent for the insurer to contact my physician and request further information as needed.
Signature
Name
Date