Bereavement form

Their full name (Required)

Their date of birth (Required)

Date of passing

Your relationship to them (Required)

Spouse/Partner

Parent

Carer

Child

Sibling

Executor/Legal Representative

Other

Main persons name on the AXA Health membership

Membership number

Other relationship

Please could we have your contact details in case we need to get in touch with you.

Your full name (Required)

Phone number (Required)

Email address (Required)

Preferred contact method (Required)

Phone call

Email

Is there anything additional you feel we should know?

Are there any questions we can help you with? We’ll reach out to you via your preferred contact method.

Here for you

Should you need to talk to someone during this time, counsellors are available to all our members through our bereavement support service, which can be accessed via our 24/7 health support line on 0800 003 004.

You can also access support by visiting - www.axahealth.co.uk/bereavement. Please don’t hesitate to reach out.

_{*All calls are confidential. We may record and/or monitor calls for quality assurance, training and as a record of our conversation.}

Here for you

Should you need to talk to someone during this time, counsellors are available to all our members through our bereavement support service, which can be accessed via our 24/7 health support line on 0800 003 004.

You can also access support by visiting - www.axahealth.co.uk/bereavement. Please don’t hesitate to reach out.

_{*All calls are confidential. We may record and/or monitor calls for quality assurance, training and as a record of our conversation.}

Bereavement contact form