Group Critical Illness Claim Notification Form

Intermediary details (if applicable)

Employer details

The group protection policy number will start with a G and is followed by 8 numbers.

Member details

Employment details

This is the date that the member started their contract of employment.

This is the date that the member joined the Group Income Protection scheme, it may not be the same date as they started employment as some schemes have qualifying periods.

This is the date the member was last at work before they went absent.

Member's partner or child details (if applicable)

(eg. If the claim being submitted is for the employee’s spouse, registered civil partner, unmarried partner or child (where covered):

Declaration by the principal employer as grantee of the policy

We declare that the above statements are accurate and complete and that the above member is eligible, in accordance with the terms and conditions of the policy and the plan issued by Legal & General Assurance Society Limited (Legal & General).

We confirm we have the explicit consent of the person(s) named in this form, or have other legal basis, to provide Legal & General this information and any further information (including medical or health information) that is required.

By signing this declaration you confirm the Insurer is:

  • fully discharged from its liabilities to you in respect of benefits for the insured member arising from the policy, and
  • fully indemnified from any further claim in this respect’

To be signed by an official of the principal employer.