Critical Illness claim form

All fields, unless otherwise specified, are mandatory. We’ll use this information to validate your identity.

Type of claim

Critical illness

Terminal illness

Total permanent disability

Children’s critical illness

Policy number

Your policy number should start with PR.

Your details

Title of the insured

First name of the insured

Last name of the insured

Date of birth

Day

Month

Year

House name or number

Address line 1

Address line 2

Town or city

Postcode

Preferred contact number

Confirm email

Preferred method of contact

Telephone

Cause of claim (diagnosis)

Date illness was confirmed

Day

Month

Year

Child's name (if applicable)

Child’s date of birth (if applicable)

Day

Month

Year

Relationship between you and the child (if applicable)

Details of your claim

Supporting you through your claim journey

If you have any communication or accessibility needs you’d like us to be aware of when interacting with you regarding your claim please use the section below to let us know.

Whether it’s documents in an alternative format (like large print or audio) or access to interpreting services like RELAY or SignLive, whatever you need we’ll do our best to ensure your journey is tailored to best suit your needs.

Communication or accessibility needs

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