DEATH CLAIM FORM Doctors part

DEATH CLAIM FORM (Doctors part)

To be completed by the Doctor certifying the insured’s death.

Name & Surname:

Date of Birth:

Residence Address:

Date of Death:

Place of Death:

Name of Hospital/Clinic:

Cause of Death (type of illness or disease, injury or complication that caused Death):

Previous health problems that might have caused the above and since when:

Other serious conditions that contributed to Death, irrelevant to the actual cause of Death and since when: