Paralysis Insurance Claim Form
Personal Information
Full Name
Date of Birth
Policy Number
Contact Number
Address
Incident & Diagnosis Details
Date of Incident
Date of Diagnosis
Type of Paralysis
Partial
Complete
Description of Paralysis
Cause of Paralysis
Hospital/Clinic Name
Attending Doctor
Doctor's Contact
Claim Details
Amount Claimed
Supporting Documents
Additional Information
Declaration
I declare that the information provided is true and correct to the best of my knowledge.
Signature
Date