Family-Protection-Insurance-Claim

Claim Process Number

1. Policy Data

Policy Number

Policyholder:

Insurance Company

2. Insured Person Data

Full Name

Address

Locality

Relationship to policyholder:

Telephone

Mobile phone

Identity Card

Tax Number

Profession

BIN (Bank Identification Number):

3. Claim Data

Participant Name:

Is this the person who will accompany the process? *YesNo

The participant must attach a copy of the Identity Card to the form. *

No file chosen

Cause of Claim

Death by accidentNatural death or by illness

Date

Time

Minutes

Location:

Description of what happened

4. Required DocumentationCopy of death certificate / death bulletinCopy of deceased person's identity cardCopy of beneficiary's identity documentCopy of medical report

All data is confidential and will only be used for the Insurance Company's internal purposes.

Attach all necessary documents.

5. Declaration1. The information has been provided with accuracy, good faith, truthfulness and I assume full responsibility for it.2. I authorize the Insurance Company to collect additional personal data from public bodies, specialized companies and other economic units, with a view to confirming or supplementing the collected elements necessary for managing the contractual relationship. Omissions, inaccuracies and falsehoods in providing information are the customer's responsibility. Access to personal data provided, under absolute confidentiality, provided it is compatible with the purpose of collecting the same.