Group Claim Form printable pdf download

Download our

Group Claim Form

MyHealth app

Quick and easy claims submission

1. Provide a few key details

Please complete this form in BLOCK CAPITALS. For your convenience, this form (PDF and editable

2. Take a photo of your receipt(s)

Word version) is available on our website:

And you’re done

1 Policyholder’s details

Policy Number

Date of birth

(dd/mm/yy)

First name

Surname

Latest correspondence address

Telephone number

(incl. country code and area code)

Do you have any national/public or state provided health insurance cover in your home country or country of residence e.g. National Health Insurance?

Yes

If Yes, please provide a description of the cover provided along with your reference number/identifier with the state.

2 Patient’s details (if different from policyholder)

3 Payment details

Payment to medical

provider*

(e.g. hospital, specialist)

Payment to policyholder

Option 1:

(The bank details requested below are not required for this option)

Option 2:

Preferred payment method:

Bank

transfer**

Cheque***

Please specify the currency you would like to be reimbursed in (and ensure that your bank account supports it)

Name of bank account holder as shown on your bank statement

Account number

IBAN (where

required)****

Sort/branch code

BIC/Swift

code****

Name of bank

Bank address

If you are aware of any additional information required in order to process international transactions within your country (e.g. Agency Code, Tax ID), please list below:

Swift code of intermediary bank (where applicable)

* If you have not already paid the medical provider. ** For bank transfer, please provide bank details. *** Cheques payable to the policyholder will be sent to the correspondence address provided in section 1.

**** If your bank is within the EU, or if your specific country requires an IBAN (e.g. Qatar, Saudi Arabia, Angola, Tunisia, Turkey), please supply both your IBAN and BIC/Swift code to facilitate the payment of your claim.

4 Claim details

Please complete all parts of the following table with the details of each invoice/receipt. Please note that for costs incurred in China, a Fa Piao invoice needs to be

submitted with all claims. If your invoice/receipt does not include the diagnosis/medical condition, please ensure that you provide us with this information below.

If there is insufficient space in the table below, please provide details on a separate page.

Description of expense/treatment

Diagnosis/medical condition

Provider’s name

Amount charged/

Has this bill been

currency

paid by you?

Yes