Claim Progress Update - Dis-Chem Life

Claim Progress Update

Before submitting this form please ensure the claim number exists on Superset. If not, the submission form must be used first.

Submitted By(Required)

Claim Number(Required)

Details

Claim Status(Required)

Closed

Open

Outcome(Required)

Reason(Required)

Decision date(Required)

YYYY dash MM dash DD

Goodwill Recoverable from Guardrisk?(Required)

Yes

No

Partial

Details of Goodwill Recovery(Required)

Amounts

Claim Amount(Required)

Please enter a number greater than or equal to 0.

Refund Amount(Required)

Please enter a number greater than or equal to 0.