Terminal Illness Claims Form

We understand that this is a difficult time. Our role is to support you and assist you in ensuring the process is as smooth and stress-free as possible. If you require further information or have any queries, please do not hesitate to contact us using the details as set out in your Policy Schedule.

We kindly ask that you ensure the following before returning this form to us:

1. Read this claims form thoroughly to ensure you understand SECTIONS 1-7 and what is required for each section.
2. Submit all required documents as listed at SECTION 7: ENCLOSURE CHECKLIST
3. The NOTES section at the end of this claims form provides clear guidance to help you navigate each question and ensure the information you provide is accurate - please review it carefully.

If the Policyholder has mental capacity, they must either complete and sign the form themselves or may provide written consent for their next-of-kin to assist on their behalf.

If the Policyholder lacks mental capacity only a person with legal authority to act on their behalf may complete the form. 

If you selected option (3) above, please provide a valid Power of Attorney authorising you to act on the Policyholder’s behalf. 

If you are NOT completing this form as the Policyholder (i.e. you selected either option (2) or (3) above) please fill out the table below:

TAKE NOTE: In this form, all references to “you”, “yours”, means the policyholder or the legal representative acting on behalf of the policyholder.

Payment of your claim will be made by direct credit to your bank account, so it is important that you complete this section properly. Please remember that once the payment reaches your account, it will take a minimum of 2 or 3 working days to clear and allow you access to your money. 

Permission to access your medical records and process your personal information 

(SEE NOTE 2 AT THE END OF THIS FORM FOR YOUR STATUTORY RIGHTS)

The Insurer will require a report from your doctor, or any medical practitioner you’ve been seeing, about your health, physical or mental. This may include details of an illness or injury you’ve suffered. Your permission is required for all necessary medical reports to be obtained by the Insurer. Your doctor can provide this via post or electronically. 

We will capture your consent for this below. This is a valid way for us to obtain your permission and is legally binding. If you do not provide us with your consent, then the Insurer may not be able to fully assess your claim.

*Option 2:

• Your doctor will be aware that you have chosen this option but you must contact them to see it within 21 days of us sending our application to them. If they have not heard from you within 21 days, they will assume that you do not wish to see it and they will send the report to us.
• If you do see the report, you have the right to request that your doctor amends the report if you believe anything to be incorrect or misleading. If your doctor is unwilling to make these changes, you may:
  • Withdraw your consent
  • Ask for a statement setting out your views to be attached
  • Or, agree to the report being issued unchanged
• Your doctor can withhold elements of the report that they believe may cause serious harm to your physical or mental health, or that of others. Your doctor will not show you information about other people without your permission

General Declaration

a) I/We confirm that I/we am/are legally entitled to make this claim on behalf of the deceased, and that all information provided is, to the best of my/our knowledge, true, complete and not misleading.

b) I/We agree to supply any additional evidence (e.g. death certificate, grant of probate, letters of administration, power of attorney) if required.

c) I/We understand that knowingly providing false, incomplete or misleading information may result in the claim being declined, recovered or legal action being taken against me/us.

d) I/We authorise payment of any benefit due under this policy to the person or entity named below (if different from the signatory), and confirm they are entitled to receive such payment.

Data Privacy

e) I/We authorise the Insurer, its reinsurers, claims assessors and appointed agents to obtain, store, process and share any personal data (including special categories of personal data) relating to the deceased and me/us from physicians, hospitals, employers, public authorities or any other third party as required to evaluate and administer this claim.

f) I/We acknowledge my/our rights to access, correct or erase personal data; to restrict or object to processing and to lodge a complaint with the UK ICO (www.ico.org.uk) or the Guernsey DPA (https://www.odpa.gg/)

g) I/We acknowledge that I/We have the right to access the Insurer’s Privacy Policy via their website: https://www.1edgeinsurance.gg/wpcontent/uploads/2025/04/1EDGE-Privacy-Policy.pdf and the Policy Distributor’s Privacy Policy via their website, as detailed in the Policy Schedule.

h) I/We are /am aware that data processing will be in accordance with:

the UK General Data Protection Regulation and Data Protection Act 2018;

the Data Protection (Bailiwick of Guernsey) Law, 2017; and

any applicable guidance of the UK Information Commissioner’s Office or Guernsey Data Protection Authority.

 

By signing below, you acknowledge that you have read, understood and consent to all declarations set ou in this SECTION 5 and 6

*If you withhold consent the Insurer may be unable to assess your claim.

NOTES

1. In order to complete this form for a policyholder where they have capacity to sign SECTION 2 above, then you must be their next of kin. If the policyholder does not have capacity to sign SECTION 2, then you must have power of attorney and be able to provide us with proof of this power of attorney.
2. Your statutory rights under “access to medical reports” law are set out in the Access to Medical Reports Act 1988 (applying in England, Wales and Scotland), the Access to Personal Files and Medical Reports (Northern Ireland) Order 1991 and the Access to Health Records and Reports Act 1993 (Isle of Man). These statutes govern how you can obtain from any doctor who has been, or is, treating you a medical report prepared for insurance purposes, and allow you to see, comment on or correct the report before it is sent. Jersey, Guernsey and Gibraltar have no equivalent “access to medical reports” legislation, so in those jurisdictions you must rely on your rights under data-protection law. Your three options under SECTION 5 explain how to request the report, how to discuss its contents with the doctor and how to challenge anything you believe to be incorrect.

Please submit the completed form and supporting documents via the digital upload link provided or alternatively send them to the authorised Policy Administrator at the address given in Your Schedule. Please also keep copies for your own records.

This product is underwritten by 1Edge Insurance PCC Limited acting on behalf of its cell, 1Edge Insurance Cell 2 ("1Edge”) and is licensed to carry on international long-term insurance business by the Guernsey Financial Services Commission ("GFSC") with GFSC reference number: 2771296. Recourse in respect of liabilities owed to a creditor is restricted to the available assets of the Cell for the time being without recourse against the core assets of 1Edge (as defined in section 467 of the Companies Law) or the assets of any other protected cell of 1Edge. 1Edge’s registered address is Suite 1 North, 1st Floor, Albert House, South Esplanade, St Peter Port, Guernsey, GY1 1AJ

Eleos Life Limited (FRN: 998550) is authorised and regulated by the Financial Conduct Authority. Eleos Life Limited is a company registered in England and Wales (Company Number 14010855), with its registered office at 71-75 Shelton Street, Covent Garden, London, United Kingdom, WC2H 9JQ.