Income Protection Claim

Income Protection Claim Notification Form

Simply fill out the claim notification form below and one of our claims specialists will be in contact with you shortly.

Fields marked with an * are required

Insured's Details

Insured First Name *

Insured Last Name *

Email Address

Phone Number *

Policy Number

Employer Name

Is the insured the preferred contact person?

YesNo

Contact Details

Preferred contact person if not the insured details provided above.

First Name

Last Name

Email Address

Phone Number

Relationship to the insured

Claim Details

Type of condition eg. illness or injury type

Description of claim *

Additional InformationPlease provide any additional information you would like to advise your claims specialist.

Upload Supporting Documents or Files

Click here to upload files to substantiate your claim eg. police report, images, quotes, invoices, photos etc.You can upload a maximum of 3 files .jpg, .png, .mov, .mp3, .mp4, .wav and .pdf only. Max size per file is 3GB.

File Upload 1

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File Upload 2

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File Upload 3

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