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Claim Form
Policy/Member Information
Patient Name Policyholder Name:
Policy Number: Member Number:
Contact Details (if different from policy)
Address:
City: Country: Email:
Telephone (home) Telephone (ofce) Fax:
Reimbursement Method
Eligible claims will be reimbursed via bank transfer. Receiving bank charges are the responsibility of the member. Please provide your bank account information below.
Bank Name
Bank Address:
Account Name: Account Number:
Sort Code: IBAN Code: BIC (Swift) Code:
Correspondent Bank Details (if applicable):
If this claim pertains to illness:
When and how did this illness rst occur? When did you rst consult a doctor about this problem or these symptoms?
Have you ever had a similar illness or symptoms? If yes, please give full details below:
If this claim pertains to an accident:
Date, time, and exact place of accident
Briey describe how this accident occured:
Was a third party involved? If Yes, please describe their part in this accident, & state whether reimbursement/compensation will be provided.
SECTION A (To be completed for all claims)
SECTION B (To be answered by member or parent if a minor)
IMPORTANT INSTRUCTIONS TO COMPLETE YOUR CLAIM:
Complete Sections A and B, and sign Declaration if:
► You are claiming only for out-patient doctor visits, medications and general laboratory tests,
► The doctor has written the diagnosis on the bill or receipt, or on a separate note, and
► You have not been advised you may require surgery, hospitalization, or specialized testing for this disability.
Complete Sections A and B, and ask your Physician to complete Section C if:
► You are claiming for in-patient, emergency, or surgical claims, or claims involving complex treatments/tests, accidental injury, or major illness.
I hereby declare that all information provided on this form and the documents submitted herewith is true and correct to the best of my knowledge and belief. The amounts claimed are the
actual charges incurred by me, are legally due to me under the terms of this policy, and are not recoverable from any other source.
Authorization for Release of Information
I authorize any doctor, hospital, or other health provider or facility, insuring or reinsuring company, or employer to release to the Insurer (“the Company”) any information or records
they may have regarding my health, tests or treatments I have received, and benets or compensation therefor. If this claim relates to an accident, past or present, I also authorize
any governmental body, agency, or other person or organization who may have records pertaining to such accident to release such records or information. I understand that this
information will be used by the Company to determine eligibility for benets, and that any information obtained will not be released by the Company to any person except to reinsuring
companies or other persons or organization(s) performing business or legal services in connection with my claim, save as may be required by law. I agree that a photocopy or facsimile
of this release shall be as effective as the original.
Signature: Date:
DECLARATION
Signature of Member (Parent if minor)
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