Severe Burns Insurance Claim Form
Personal Details
Full Name
Policy Number
Date of Birth
Address
Phone Number
Email Address
Incident Details
Date of Incident
Location of Incident
Description of Incident
Degree of Burns
Area of Body Affected
Were you hospitalized?
Details of Treatment Received
Medical Information
Name of Hospital / Clinic
Attending Physician
Physician Contact Information
Date of Admission
Date of Discharge
Additional Information
Other Insurance Coverage
Additional Comments
Declaration
I declare that the information provided is true and correct to the best of my knowledge.
Signature
Date