Ιατρική Έκθεση – Αποδεικτικ ό Θανάτου.pdf

3.2 Medical Report
Death Certificate
To be completed by the doctor who certified the death of the insured.
INSURED DETAILS:
Name:
Date of Birth:
Address:

INCIDENT DETAILS:
Date of Death:
Place of Death:
Hospital/Clinic Name:
Cause of Death (type of illness, injury, or complication that caused death):
Previous causes that led to the above cause and when they started:
Other serious conditions that contributed to death but are unrelated to the condition that caused death and when they started:
Date of first examination for the last illness:
Date of last examination for the last illness:
Duration of illness that caused death:
Was the death due to illness □ accident □ suicide □ or homicide □
(Describe)
Was an investigation conducted? YES □ NO □
Was an autopsy performed YES □ NO □
Conclusion:
Did you examine or advise the deceased during the last 3 years before the last illness? YES □ NO □
Examination Date
Illness

Do you know if the deceased was examined during the last 3 years by any doctor or hospitalized in any hospital or clinic? YES □ NO □
Date
Hospital/Clinic
Doctor's Name

As far as I know, all the above statements are true.

Doctor's Name…………………………………………………………………………..Signature………………………………………………………

Specialty…………………………………………………………………………………Date……………………………………………………

ATTENTION: Together with the application form, all necessary certificates (originals) must be submitted.

Necessary documents for a death benefit claim

1.
Application Forms (fully completed) (Within 6 months from the day of death certification)
2.
Insurance Contract or Declaration/Loss Certificate
3.
Birth and Death Certificates of the Insured
4.
Copy of Insured's ID
5.
Autopsy report if performed. If not performed, a certificate from the doctor who certified the death must be submitted, stating the reason for not performing the autopsy.
6.
Medical history if the Insured was hospitalized before death
7.
Tax Clearance Certificate from the Director of the Inland Revenue Department (Forms Ε. Πρ. 703- Ε. Πρ. 704)
8.
Document of Deceased's Estate Management (issued by the court)