Sample Claim Form
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1
2Overseas Visitors
Health Cover
Claim form
Please complete both sides of this application in CAPITAL letters. Post or fax the application to Allianz Global Assistance OVHC with all
required attachments.
Policy holder details
please tick if your address has changed
Policy number (must be provided):
Type of policy:
Budget Visitors
Visitors Plus
Single plan
Dual family plan
Multi-family plan
Family name (surname):
Title:
Dr
Mr
Mrs
Miss
Ms
Given name:
Other name/s:
Date of birth:
_ _ /_ _ /_ _ _ _
Gender:
M
F
Address:
Postcode:
Daytime contact number:
Mobile:
Email address:
Passport number:
Nationality:
Details of expenses claimed
Date of service
Have you already
Provider of service
(dd/mm/yyyy)
Amount of
Patient‘s first name
Provider number
paid for this
(e.g. Dr Jones)
(e.g. doctor visit or
invoice
service?
medicine purchase)
1.
$
__/__ /____
yes
no
2.
__/__ /____
$
yes
no
3.
$
__/__ /____
yes
no
4.
$
__/__ /____
yes
no
5.
__/__ /____
$
yes
no
If accounts are unpaid, payments will be made directly to the provider. Please direct any enquiries from the provider to
Allianz Global Assistance
.
•
If accounts are paid, original tax invoices and receipts must be attached to process your claim.
•
If you hold a family policy (including dual family and multi-family policies) and are submitting a claim for a dependant covered by that policy, you
•
must ensure your dependant‘s details are registered on your policy. You can do this in the ‘Members’ section of the website or call our Members
Services on 1300 727 193.
This section must be completed for all claims
Are the expenses related to one of the following?
Work accident
Motor vehicle accident
Not an accident
Other type of accident (please specify)
Are the expenses claimed for a medical assessment, x-ray or blood tests required for the renewal or issue of your eligible visa?
yes
no
Please Note: You are required to provide a copy of your current eligible visa when making a claim.
Total amount of all claims lodged in this instance: $
PLEASE TURN OVER AND COMPLETE PAGE 2 OF THIS FORM.
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