Policyholder's full name^*

Policy number^*

Date of birth^*

First line of address^*

Postcode^*

Date of death^*

Was the policyholder in hospital at the time of their death?^*
—Please choose an option—YesNo

Are there any outstanding claims for the last 12 months?
—Please choose an option—YesNo

Please note any payments will depend on the terms and conditions of cover and any previously submitted claims.

Full name^*

Relationship to the deceased^*

Address for correspondence^*

Postcode^*

Telephone^*

Email^*

Are you the policyholder's next of kin?^*
—Please choose an option—YesNo

Does anyone else covered on the policy want to continue their cover?^*
—Please choose an option—YesNo

Full name of the person requesting payment^*

Bank name^*

Name on account^*

Sort code^*

Account number^*

I declare that:
The information provided in this form is true, complete, and accurate to the best of my knowledge.

The person captured in the payment details is authorised to submit this claim and receive the bereavement funds on behalf of all persons entitled to a share of the funds, and that I am not aware of any other person or persons with an entitlement to the funds.

In return for Sovereign Health Care agreeing to make the payments requested by me, I (together with any other person I am submitting this claim for) agree to indemnify and keep indemnified Sovereign Health Care against all demands, claims, liabilities, losses, charges, and expenses which Sovereign Health Care may incur if this declaration proves to be incorrect for any reason.