Critical Illness Cover, terminal illness, Total Permanent Disability, and children’s critical illness claim form

Details marked with * must be completed in full.

Type of claim:

Critical illness Terminal illness Total permanent disability Children’s critical illness

Policy number:

Your details

Title of the insured:

First name of the insured:

Last name of the insured:

Date of birth:

House name or number:

Address line 1:

Address line 2:

Town:

Postcode:

Preferred contact number:

Email address:

Confirm email address:

Preferred method of contact:

Email Telephone

Cause of claim (diagnosis):

Date illness was confirmed:

Child’s name (if applicable):

Child's date of birth (if applicable)

Relationship between you & the child (if applicable)

Details of your claim: