We would like to help you with your claim application. Please fill out the form below and complete all fields marked with (*).

Before submitting your application, please prepare the following documentation for your convenience in the next steps.

1. Police Report

2. Hospital Bill

3. Medical Certification confirming the planholder's disability / dismemberment

4. Medical Records (laboratory results, Medical History, Abstract, etc.)

5. Photocopy of Valid IDs of Planholder (Government-issued ID’s)

LPA Number:*

Claimant's First Name:*

Claimant's Middle Initial:*

Claimant's Last Name:*

Mobile Number:*

Email Address:*

Cause of Dismemberment:*

Date of Dismemberment:*

Date of Medical Certificate:*

Relationship to the Planholder:*

Police Report*

Hospital Bill*

Medical Certification*

Medical Records*

Photocopy of Valid IDs of Planholder*