This form should be filed by the insured. Only in exceptional cases, when the insured is disabling due to health and/or physical conditions, the form will be completed by a relative in the presence of the insured or by a person authorized by the relatives of the insured according to the legal provisions in force. In case when the insured has passed away, this form should be filed by the claimant relative/relatives. For issues and matters not specifically stated in this form, the relevant insurance terms and conditions are applied. SiCRED sh.a. preserves the right to request additional information and documents as well as any other data necessary to estimate this claim.I authorize any physician, hospital employees, hospital, clinic, public or private medical institution, to disclose any information regarding my medical records. I am aware of the general insurance terms and conditions and I am also aware that if I/we fail to provide the required documents to the Insurance Company, the later has the right to not proceed this claim request and to refuse the claim payment.I declare in my full responsibility that the above given information is true and accurate. If any of the above declarations is found fraudulent, I declare in my full responsibility to waive from this claim request or any other request related to it.

Declarer

SiCRED sh.a., guarantees that the data collected using this application, will be processed in full compliance with the predictions of the Law no. 9887 dated 10.03.2008 "On personal data protection" (as amended). As the subject of these data, you have all the right as prevised by the law. SiCRED sh.a., have in place a high standard security system for storing and further processing of these data.

Insured Personal Data:

Insurance data:

Claim Amount related to the event for which you are applying:

*All the original supporting documents should be sent via regular mail in the address: SiCRED sh.a., Administrative Unit No.5, “Brigada VIII” Str., Building No3/1, Tirane,  Albania

SiCRED sh.a., guarantees that the data collected using this application, will be processed in full compliance with the predictions of the Law no. 9887 dated 10.03.2008 "On personal data protection" (as amended). As the subject of these data, you have all the right as prevised by the law. SiCRED sh.a., have in place a high standard security system for storing and further processing of these data.