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Policyholder information

Full name :

Policy number :

Contact number :

Email address :

Address :

Policy information

Has the policy document been misplaced?YesNo

Has this policy been assigned to a funeral service provider or memorial institution?YesNo

If so, please attach a copy of the assignment documentation.

Has the name of the beneficiary been updated or changed?YesNo

If yes, please explain

Claimant details

Claimant’s name :

Date of birth :

Your relationship to the insured :

Contact number :

Identification document :

Identification number :

Claimant’s address :

Claim concern :

Please describe the incident or issue that led to this claim in detail. Include information about when and where the event occurred, the circumstances surrounding it, and any contributing factors that may have caused the loss or damage. If applicable, mention any third parties involved and the immediate steps taken to mitigate the situation.

Provide a clear summary of the damage, injury, or loss sustained, along with any supporting evidence such as photos, reports, or receipts. The more specific and accurate your description, the faster and more efficiently we can process your claim. Our team may contact you for clarification or additional details if required.

Claim details

Type of insurance :

If others :

Date of incident :

Time of incident :

Location of incident :

Description of loss/incident :

Bank details for payment (if approved) :

Bank name :

Account holder name :

Account number :

Account type :

Routing number(ABA) :

I confirm the bank details are correct and authorize to make payments to this account.

By submitting this claim form, you confirm that all details provided are true and accurate to the best of your knowledge. False or misleading information may result in claim rejection or legal action. The insurer reserves the right to verify all details before approving payment.

Declaration and signature

I hereby declare that all the information provided in this claim form is true and accurate to the best of my knowledge and belief. I understand that any false or misleading state I hereby declare that all the information provided in this claim form is true, complete, and accurate to the best of my knowledge and belief. I fully understand that any omission, misrepresentation, or false declaration made intentionally or unintentionally may lead to the rejection of this claim, recovery of any amounts already paid, cancellation of the policy, or initiation of legal or disciplinary action by the insurer. I acknowledge that the accuracy of every statement is essential to ensure fair and transparent processing of my claim, and I take full responsibility for the correctness of all details, documents, and evidence submitted in connection with this form. Furthermore, I confirm that I have personally reviewed all entries before signing and that no relevant facts have been withheld that could affect the insurer’s assessment or liability.ments may result in the denial of my claim or other legal action.

By signing below, I acknowledge that I am the claimant or a duly authorized representative of the claimant and that I accept full responsibility for the accuracy, completeness, and truthfulness of all details submitted in this form. I further understand that the insurer reserves the right to request further clarification or evidence as part of the claim assessment process.

Ensure all details are correct before signing
Attach required documents and supporting evidence
Provide clear copies of any receipts, reports, or photos related to the claim
Contact our claims team for clarification or assistance if required
Keep a copy of this form and all attachments for your personal records

Signature :

Date :

Submit for claim

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