Cancer Insurance Claim Form
Policyholder Information
Full Name
Policy Number
Date of Birth
Contact Number
Email Address
Address
Patient Details
Is the patient the policyholder?
Yes
No
Relationship to Policyholder
Patient Full Name
Date of Birth
Gender
Female
Male
Other
Cancer Diagnosis Information
Date of Diagnosis
Type of Cancer
Stage / Grade (if known)
Hospital / Clinic Name
Attending Physician
Treatment Details
Treatment Type
Treatment Start Date
Treatment End Date
Details of Treatment Received
Claim Details
Amount Claimed
Bank Account Name
Bank Account Number
IFSC / SWIFT Code
Declaration & Signature
I hereby declare that the information provided above is true and correct to the best of my knowledge.
Signature
Date