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Disability Claim Form

Please Note that Benefits shall be payable on total, permanent and irreversible disability as arising from accidental cause(s) as assessed by the Insurer.

 

Econet Life must be notified that a Claim is being made as soon as reasonably possible of confirmation of the disability, but in any event no later than 60 days from date of confirmation of disability.

 

Econet Life reserves the right to call for any additional documentation as may be required from time-to-time to validate the information provided and the Policy Holder or Beneficiary shall supply in writing at his/her own cost any reasonable information that the Insurer may request.

Member Details

Details of the accident

Physician or Hospital treating you for this disability

I also certify that following the accident, I have sort medical assistance from a qualified Medical Officer(s) and I have/I am following ALL the advice or course of treatment recommended.

Claimant Details (If different from member)

Required Documents

I HEREBY DECLARE that I am the person assured under this policy or the policyholder’s appointed representative and that the accident and resultant disablement was not due in any way whatsoever to indulgence in alcoholic liquor or to the use of drugs of any kind and that the stated disablement did not exist prior to the policy commencement date.

I FURTHER DECLARE THAT THE ABOVE REPLIES ARE TRUE IN EVERY PARTICULAR and agreed that if any FALSE statement was made by me or if withheld any material fact in connection with my claim for compensation my right to compensation under the above policy shall be FORFEITED.

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime, and subjects such person to criminal and civil penalties.)