Claim Form
Deceased Information
Reference Number
*
Full Names
*
First Name
Last Name
Claimant
*
Policy Holder
Nominated Client
Full Names
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Relationship to the deceased
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please upload the following documents
1.BI Letter | 2. Death Certificate | 3. Id Copy ( Deceased ) | 4. Id Copy (Claimant)
Upload the documents above
*
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I hereby confirm that the information provided above is true to the best of my knowledge.
I hereby confirm that the information provided above is true to the best of my knowledge.
*
Yes I confirm
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