Claims Form

For detailed information about the Claims process, click here.

Personal Data
Name*
Name Surname
3rd Party (Next of kin, Sibling, Spouse, Legal Representative)
- I am not the insured
Relation
Phone Number*
Address*
Email Address*
Preferred Method of Contact*
Preferred Contact Time*
Insurance / Contract Ref Number
Insured’s Date of Birth*
Gender
Claim Required*
Event Date*
Injury Data - Reason of Claim
Terms and Conditions*
- I have read and agree to the Terms and Conditions

This site is registered on wpml.org as a development site.