Making a claim.

We aim to make the claiming process as simple and stress free as possible.

The insured member is required to complete the following claim form and attach all the original medical bills and supporting documentation when filing the claim. A separate form must be completed for each medical condition, each currency and each member. All sections must be completed.

Personal Data provided in this claim form or submitted as part of this claim will be used and processed by us in line with our Privacy Policy which can be requested from us at any time.

Please click here to download the claim form as a pdf – you will need page 2 to give to your doctor.

If the form below does not appear immediately, please refresh this page.

SECTION A: PATIENT DETAILS TO BE COMPLETED BY INSURED MEMBER

Name of Main Applicant *

Membership Number: *

Date of Birth *

Present Contact Address: *

Telephone Number: *

Email Address for Remittance Advice *

If the person named above is not the patient, please complete details

SECTION B: SETTLEMENT DETAILS

We settle all eligible claims by bank transfer (EFT), therefore it is important that you confirm your correct bank details every time you make a claim. Should the incorrect bank details be provided we reserve the right to charge an administrative fee to cover any charges incurred due to the error.

Total amount claimed (including currency): *

Currency of Reimbursement: *

Bank Transfer – All fields in the box below are MANDATORY:

If the account holder is not the claimant then you must state their relationship with the claimant and provide evidence of their permission for the funds to be transferred to their account (except in the case of a minor):

Name of Account Holder (as it appears on bank statement) *

Relationship to claimant *

IBAN where applicable

Routing/intermediary information if required

Beneficiary Bank Account number (only if IBAN not applicable)

Account Holder Address (residential address registered with the bank): *

Name of Bank, Branch and Location: *

Swift Code/BIC:

Sort Code (for UK banks only):

PLEASE NOTE:

• It is important that you complete the bank details section in full. Any missing or unclear information may result in payments being delayed.

• Bank charges may apply when making bank transfers

• Payments are not made directly to any clinic, physician or medical provider

• If IBAN numbers are not used please ensure that the account number is entered and that the Swift Code/BIC is also completed.

SECTION C: PATIENT DETAILS TO BE COMPLETED BY TREATING DOCTOR

Note: If there are multiple doctors, this section is to be completed by the last attending physician.

Diagnosis (BLOCK CAPITALS PLEASE) *

Date of First Consultation? *

Onset Date of Symptoms: *

Date Treatment Received: *

Nature of Treatment: *

Name of Physician/Surgeon and Qualifications: *

Name of Clinic: *

Address of Clinic: *

Doctor or Clinic Telephone Number: *

Doctor or Clinic Email Address *

SECTION D: UPLOAD SECTION

Please upload your documents below, failure to do so will delay your claim

Medical report upload *

Receipts upload *

DECLARATION & AUTHORISATION

(This part must be signed by the patient or patient’s parent/legal guardian if the patient is below 18 years of age). I hereby authorise any hospital, physician, person or organisation to disclose all information with respect to any illness, injury, medical history, consultations, prescriptions or treatment, and copies of all hospital or medical records. A photostat copy of this authorisation shall be considered as effective and valid as the original.

I certify that the above statements and answers are true and complete to the best of my knowledge and belief. *

I Agree

Main Applicant *

Date *

Patient *