Critical Illness Claim Form
SECTION 1 - Certificate holder Information
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Name
First Name
Last Name
Employer Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
 -
Month
 -
Day
Year
Date
Gender
Female
Male
Other
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
SECTION 2 - Patient Information
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Same as Section 1Â (If you check this box, you do not need to complete this section. You may skip to Section 3.)
Select
Spouse / Child
Please Select
Spouse
Child
Patient Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
 -
Month
 -
Day
Year
Date
Gender
Female
Male
Other
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
SECTION 3 - What Type of Condition Are You Claiming?
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Please select the condition that applies to your claim.
Please Select
Cancer
Heart Attack
Alzheimer’s Disease
Coronary
Artery Bypass Graft
Stroke
Kidney Failure
Major Organ Transplant
Refer to your group certificate or Summary Plan Description for a complete description of these benefits.Not all plans include these benefits.
If the claimant is deceased, select and provide a copy of the death certificate.
Please Select
Addison’s disease (adrenal hypofunction)
Amyotrophic lateral sclerosis (Lou Gehrig’s disease) Cerebral palsy
Cerebrospinal meningitis (bacterial)
Cystic fibrosis
Diphtheria
Encephalitis
Huntington’s disease (Huntington’s chorea)
Legionnaire’s disease
Malaria
Multiple sclerosis (definitive diagnosis)
Muscular dystrophy
Myasthenia gravis
Necrotizing fasciitis
Osteomyelitis
Poliomyelitis
Rabies
Sickle cell anemia (excluding sickle cell trait)
Systemic lupus erythematosus (SLE)
Systemic sclerosis (scleroderma)
Tetanus
Tuberculosis
Submit
Should be Empty: