Form Frm-Cf - Claim Form Page 2
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44 Claim details
Please complete all parts of the following table with the details of each invoice/receipt, making sure to include the amount charged. If your invoice/receipt
does not include the diagnosis/medical condition, please ensure that you provide us with this information below. If there is not sufficient 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
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
In what country did the treatment take place?
Has pre-authorization been obtained?
Yes
No
If this claim is resulting from an accident or work-related illness/injury and you hold any other insurance policy (e.g. car insurance), or if you are filing a claim or lawsuit against a
third party to recover the costs incurred as a result of this accident/injury, please provide details in a separate document.
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