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Claim Life Insurance Submission

I hereby declare and certify the following in respect of this Insurance Claim Form:

I have filled out the Form fully, truthfully and accurately.
The Form does not contain any false, misleading or incomplete information.
I understand that any mistakes, exaggerations, inaccuracies, frauds or other defects in filling in/presenting the Form may result in my insurance cover being amended or cancelled, may reduce the amount payable in respect of the claim or result in refusal to pay it, as well as in my obligation to return payments already received from the Insurer.
I understand that a person who knowingly and with the intent to defraud an insurance company or other person, files an application for insurance or a claim with false information or conceals information for the purpose of misleading, may be guilty of committing a fraudulent insurance act.
I hereby ask to transfer all amounts due to me based on this Form and its related claim to the bank account as specified by me above. I herewith further declare that if any transaction is delayed or not effected at all, or is wrongly credited to any other account due to my fault or due to circumstances depending on me (e.g. due to incomplete or incorrect information as provided by me above), I shall not hold the Insurer responsible for it.

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Timestamp

Audit

02/09/2020 11:41 CEST

Claim Life Insurance Submission Uploaded by daily health insurance group - admin@dhig.net IP 10.70.0.52

02/09/2020 11:53 CEST

Claims Department - claims@dhig.net added by daily health insurance group - admin@dhig.net as a CC'd Recipient Ip: 10.70.0.52