Critical Illness Disability Claim Statement
Personal Information
Full Name
Date of Birth
Policy Number
Contact Number
Address
Diagnosis Details
Nature of Critical Illness
Date of Diagnosis
Attending Physician/Clinic
Description/Comments
Work Status
Current Occupation
Are you currently working?
Date Last Worked
Describe how your illness prevents you from working
Treatment Information
Type of Treatment/Medication
Next Appointment Date
Declaration
Signature
Date