Maladies graves – Déclaration du médecin
Family of condition-specific physician statements for Humania critical illness claims.
- Completed by
- Attending physician
- Issued by
- Humania
- Format
- Language
- French
Humania Preuves de décès: Déclaration du médecin
Humania Assurance asks the deceased's physician for this two-page French statement as proof of death on a life insurance claim. It follows the international medical certification of death: the disease or condition directly causing death, antecedent causes ending with the initial one, other significant conditions and the interval between onset and death. Humania's forms page lists it with the claimant's declaration (4300-012) and a death authorization (4300-018).
Who completes it
The physician completes Part A, information on the deceased and the causes of death, and Part B, their own details including specialty, licence number and clinic or hospital. The claimant completes the separate Décès Déclaration du demandeur (4300-012).
Submitting and payment
- How to submit it
- Humania's forms page accepts documents by online request where available, email, fax or mail, and strongly recommends the web process, a secure electronic channel or mail for confidential information.
- Who pays
- The form states that all fees for completing it are charged to the claimant.
Good to know
- Enter only one cause on each of lines (a), (b) and (c); line (a) is the disease, injury or complication that caused death, not the mode of dying such as heart failure or syncope.
- The form asks whether the deceased smoked, since when, and when they stopped, along with the dates of first and last care for the last illness.
- You state whether you treated the deceased in the 5 years before the last illness and list other physicians, hospitals or institutions that treated them in that period.
- If death resulted from an accident, suicide or homicide, specify which and describe it briefly, and indicate whether an inquest or autopsy took place, by whom and with what findings.
Get the official form
Download the current version from the source each time; forms change without notice.
Preuves de décès – Déclaration du médecin
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.
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.
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Frequently asked questions
Is Humania's proof of death physician statement available in English?
Humania publishes form 4300-016 in French only, as Preuves de décès, Déclaration du médecin, revised October 2023. Its forms page lists it under death claims with the Décès Déclaration du demandeur (4300-012) and the Autorisation en cas de décès (4300-018).
Who pays for Humania form 4300-016?
The claimant. The form states that all fees for completing it are the responsibility of the claimant (demandeur de règlement). In Part B it also asks the physician for an email address, licence number, specialty and the name of the clinic or hospital, along with phone and fax numbers.