report claim - pfa critical illness

Phone
*
E-mail
*
Civil reg. No.
*
Diagnosis
*
Date of diagnosis
*
Name and address of doctor or hospital
*
Yes
No
*
If yes, date when the sickness absence began
Yes
No
*
If yes, date of previous diagnosis
Yes
No
*
If yes, which diagnosis
If yes, approximately when
Phone
E-mail
*