DREAD DISEASE CLAIM FORM (Insured part)

Policy Number:

Name of Insured:

ID Number:

Residence Address:

Telephones:

Work Address:

Telephones:

Date of the Disease commencement:

Disease Details:

Diagnosis:

First symptoms and when firstly appeared:

Did you ever receive any treatment in a Hospital/Clinic for this disease?

Yes

If YES, please write when and where: