Critical illness, terminal illness and children’s critical illness claim form

Details marked with * must be completed in full.

Policy number:

Type of claim:

Critical illness

Terminal illness

Children’s critical illness

Your details

Title of the insured:

First name of the insured:

Last name of the insured:

Date of birth (dd/mm/yyyy):

dd/mm/yyyy

House name or number:

Address line 1:

Address line 2:

Town:

Postcode:

Preferred contact number:

Email address

Confirm email address

Preferred method of contact:

Cause of claim (diagnosis):

Date illness was confirmed:

dd/mm/yyyy

Child’s name (if applicable):

Child’s date of birth (if applicable):

dd/mm/yyyy

Relationship between you & the child (if applicable)

Details of your claim: