Claimant Information
Claimant Name
Claimant Surname
Claimant ID Number
Claimant Contact Number
Claimant Address
Network Provider	Select Network Provider
Relation to Deceased	Select Relation
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Search for a policy

Search By Main Member		Select criteria				Search
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Member Types: (M) - Main Member. (S) - Spouse. (C) - Child. (E) - Extended

Policy Number	ID Number	Member Full Name	Select
{{Member.PolicyNumber}}	{{Member.IdNumber}}	{{Member.FirstName}} {{Member.Surname}} ({{Member.MemberType}})

Select a policy member
Our condolences for your loss. Please select the member of the policy to claim against them.
Deceased details
Claim For	Select a member
Relation	Relation to the deceased
Place of death
Date of death
Type of claim	Type of claim
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Doctor & Undertaker Information
Doctor Name
Doctor Practice Number
Undertaker Name
Undertaker Reg Number
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