Benign Brain Tumor Claim Form
Policy Holder Details
Full Name
Date of Birth
Policy Number
Contact Number
Address
Patient Details
Patient Name
Relationship to Policy Holder
Date of Birth
Gender
Male
Female
Other
Medical Information
Date of Diagnosis
Name of Treating Doctor
Hospital/Clinic Name
Description of Condition
Claim Details
Claim Amount
Other Health Insurance Coverage
Supporting Documents
Diagnosis Report
Medical Bills
Other Documents
Declaration
I hereby declare that the information provided is true and correct to the best of my knowledge.
Signature
Date