Critical Illness Insurance Claim Form
Policyholder Information
Full Name
Policy Number
Date of Birth
Contact Number
Email Address
Address
Illness Details
Critical Illness Diagnosed
Date of Diagnosis
Treating Physician / Hospital
Physician / Hospital Contact
Description of Illness / Diagnosis
Bank Details for Claim Payment
Account Holder's Name
Bank Name
Account Number
Bank IFSC/Swift Code
Declaration
Signature
Date