Critical Illness Disability Insurance Claim Statement
Personal Information
Full Name
Date of Birth
Policy Number
Contact Number
Address
Diagnosis Details
Diagnosis
Date of Diagnosis
Hospital/Clinic Name
Attending Physician
Description of Symptoms
Employment Details
Employer Name
Occupation
Current Work Status
Last Date Worked
Declaration
I declare that the information given is true and complete to the best of my knowledge.
Signature
Date