Tell us of a bereavement

We're really sorry for your loss. Please complete the questions below so we can help you as swiftly as possible at this difficult time

All fields are required unless labelled optional.

Policy Detail

Policy Number

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Confirm Policy Number

Policy number should match

Policy Holder Name

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First line of address

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Postcode

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Deceased Member Is this the same as above?

Name

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Date of birth

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Date of death

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Relationship to Policy Holder

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Hospital stay Was there a stay in hospital prior to the member's death?

Name of hospital or hospice

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Hospital stay from

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Hospital stay to

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Outstanding claims Are there any outstanding claims to be submitted? (optional)

Claim details

Please fill in the text box below with any outstanding claims

Please note, any payments will depend on the Terms and Conditions of the cover available and any remaining entitlement under the plan

Next of kin

You will need to provide copy of death certificate unless you are the spouse.

Name

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First line of address

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Postcode

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Email

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Phone number

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Relationship to the deceased

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Contact details Is this different from next of kin?

Name

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Email

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Phone number

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Relationship to the deceased

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Continue cover Does anyone covered by the policy wish to continue? (optional)

Payment details

Name of the person requesting payment, if applicable

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Bank details for any payments due:

Bank name

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Name on account

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Sort Code

Please enter a valid sort code

Account number

Please enter a valid account number

Declaration and indemnity from the person claiming

I declare that:

The information provided in this form is true, complete and accurate to the best of my knowledge; Please complete this field

The person captured in the payment details is authorised to submit this claim and receive the bereavement funds on behalf of all persons entitled to a share of the funds and that I am not aware of any other person or persons with an entitlement to the funds; and Please complete this field

In return for Simplyhealth agreeing to make the payments requested by me, I (together with any other person I am submitting this claim for) agree to indemnify and keep indemnified Simplyhealth against all demands, claims, liabilities, losses, charges and expenses which Simplyhealth may incur if this declaration proves to be incorrect for any reason. Please complete this field

Additional information

Please send a copy of the death certificate and any supporting documentation from hospital or GP to confirm inpatient stay (where applicable) to [email protected]
We recommend that you do not send us original documents if this can be avoided
If you are unable to send via email, please send this information to Bereavements Team, Hambleden House, Waterloo Court, Andover SP10 1LQ.
Please note that some of our renewal letters and marketing mailings are produced a few weeks before they are issued. Please accept our sincere apologies should you still receive letters addressed to the deceased member in the next few weeks.

Any other information? (optional)