Partner/Child claim notification

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Employee details

Employee title

Employee first name

Employee last name

Employee phone number

Employee email address

Confirm employee email address

Employee date of birth

Employee address line 1

Employee address line 2 (optional)

Employee town/city (optional)

Employee postcode

Name of the company you work for

Employee staff number (if known)

Enter the date you joined your employer's Group Critical Illness policy if you know it

Partner/Child details

Partner/Child title

Partner/Child first name

Partner/Child last name

Partner/Child phone number

Partner/Child email address

Confirm Partner/Child email address

Partner/Child date of birth

Partner/Child address line 1

Partner/Child address line 2 (optional)

Partner/Child town/city (optional)

Partner/Child postcode

Partner/Child diagnosis

Date when symptoms first started

Has the Partner/Child suffered with this condition before?

Please give us the contact details for your partner/child's GP

What is the Partner/Child's consultant details

Do you have any medical information surrounding your Partner/Child medical condition that we could get from you?

Any other comments (optional)

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Employee details

Partner/Child details

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