MEDICAL AND EMERGENCY EXPENSES / HOSPITAL BENEFIT / PERSONAL ACCIDENT (INCLUDING ADDITIONAL TRAVEL, ACCOMODATION EXPENSE)
I ) DOCUMENTS REQUIRED : The following documents must be enclosed with your completed claim form :
ORIGINAL CERTIFICATE OF INSURANCE TOGETHER WITH ANY COPIES OF AIRLINE TICKET
ORIGINAL BILLS OR RECEIPTS FOR FULL AMOUNT OF CLAIM ( PHOTOCOPIES NOT ACCEPTABLE )
CONFIRMATION BY HOSPITAL OF DATES OF HOSPITALISATION ( FOR CLAIMS FOR HOSPITAL BENEFITS )
DEATH CERTIFICATE ( FOR COMPENSATION CLAIM OF DEATH BY ACCIDENT )
DISABLEMENT CERTIFICATE AND POLICE REPORT ( FOR PERSONAL ACCIDENT CLAIM )
THE MEDICAL CERTIFICATE DOES NOT NEED TO BE COMPLETED FOR MINOR ACCIDENTS OR ILLNESS
PHYSICIAN’S REPORT ( ORIGINAL ATTACHED TO THE POLICY IF APPILCABLE )
These documents must be supplied with the completed claim form at the Claimant’s expense. Failure to do so will delay the processing of your claim and could result in it being declined.
II ) TO BE COMPLETED BY THE CLAIMANT OR THE CLAIMANT’S LEGAL REPRESENTATIVE :
Name of Sick or Injured Person
2. 3. 4. 5.
Nature of Injury / Illness Date of Injury / Illness Place of Injury / Illness Circumstances of Injury
: : : :
If claim was due to hospitalization or confinement, was the Emergency Assistance Department contacted YES / NO. If no, please advise why, on an additional information sheet.
Dates of Hospitalization
Details of Claim
: From - :
Details of any third parties involved in accidental injury or death of insured person.
Details of Private Health Insurance
a) b) c) d)
Name of Insurer
Address of Insurer : Policy Number : Telephone Number :
Details of Claimed Expenses, Providers Name, Prescription Charges, etc.
Amount Charged in Local Currency
IMPORTANT Has Bill Been Paid By You* YES / NO YES / NO YES / NO YES / NO YES / NO YES / NO YES / NO
*Delete where Applicable