Kidney Failure Insurance Claim Form
Policyholder Name
Policy Number
Date of Birth
Contact Number
Email Address
Patient Name
Relationship to Policyholder
Patient Date of Birth
Date of Diagnosis
Treating Hospital/Clinic
Consulting Doctor's Name
Details of Kidney Failure Diagnosis
Treatment Received (Dialysis, Transplant, etc.)
Claim Amount
Bank Account Details for Payout
Additional Comments
Date
Signature