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Humania Maladies graves: Déclaration du médecin

Humania Assurance publishes a separate French-language physician's declaration for each critical illness it lists: heart attack, coronary bypass, cancer, stroke, multiple sclerosis, autism and deafness. The treating physician confirms the diagnosis against condition-specific criteria and records key dates and history. Humania's forms page lists these declarations with the Maladies graves Demande de règlement (4300-045), the insured's claim request.

Who completes it

The treating physician completes Part 2, the diagnosis questions, and Part 3, their identification with specialty, address, phone number and signature. The patient or insured person completes and signs Part 1, authorizing release of the claim information to Humania Assurance.

Submitting and payment

How to submit it
Humania's forms page lists four ways to send documents (online request where available, email, fax and mail) and strongly recommends the web process, a secure electronic channel or mail for confidential information.
Who pays
Each declaration states that it is up to the patient or insured person to have the form completed and to pay the fees.

Good to know

  • The cancer version asks whether the tumour shows uncontrolled multiplication of malignant cells with tissue invasion, plus stage, classification, site, nodal involvement and distant metastases, with a pathology report.
  • The heart attack version asks about chest pain, recent ECG changes with Q waves and localized T-wave inversion, and abnormal cardiac enzymes, with copies of the ECGs and enzyme results.
  • Each version asks for four dates: first symptoms, first consultation with any physician, first consultation with you, and when the patient first became aware of the problem.
  • All versions ask about smoking history and immediate family history, and request copies of specialist, hospital and pathology reports, tests and other evidence supporting the claim.

Get the official form

Download the current version from the source each time; forms change without notice.

Maladies graves – Déclaration du médecin (condition-specific)

Maladies graves – Déclaration du médecin

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

See how Vero Documents works

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Is the Humania critical illness physician statement available in English?

Humania publishes these declarations in French only. Its forms page lists seven versions: crise cardiaque (4300-044), pontage coronarien (4300-046), cancer (4300-047), AVC (4300-048), sclérose en plaques (4300-060), autisme (4300-061) and surdité (4300-066). Use the one that matches the condition being claimed.

Who pays for the Humania Déclaration du médecin?

The patient. The cancer declaration states that it is the patient's responsibility to have the form completed and to bear the fees, and the heart attack version says the same of the insured person. Both ask you to attach specialist, hospital and pathology reports, tests and analyses that support the claim.

How should a completed Humania declaration be sent?

Humania's forms page lists online requests where available, email, fax and mail. It strongly recommends the web process, a secure electronic channel or mail, and strongly discourages sending confidential information by regular email, which matters for a document containing diagnoses and pathology results.