Superior Health Cover - Claim Form
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1
2Application / Policy No.
Superior health cover - claim form
Important information you must read before submitting this claim
•
A GP referral letter must be attached to this claim form
•
An estimate of costs must be attached to this claim form for surgical procedures
•
Claims must be submitted within 12 months from the date of treatment.
Are you applying for prior approval?
Yes
No
Prior approval requires fi ve working days to be processed, provided all requested information is submitted.
Please be aware that it may be necessary to request further information before completing the assessment of your claim.
1. Policy Owner
Title
First names
Surname
Street Address
Suburb
Town/city
Postcode
Postal Address
(if different from street address)
Suburb
Town/city
Postcode
Phone No.
(
)
Home (
)
Mobile (
)
Business
(
)
Email
Fax No.
/
/
Date of birth
2. Claimant
(if claimant is not the Policy Owner)
Title
First names
Surname
Street address
Suburb
Town/city
Postcode
Postal address
(if different from street address)
Suburb
Town/city
Postcode
Phone No.
(
)
Home (
)
Mobile (
)
Business
(
)
Email
Fax No.
/
/
Date of birth
3. Claim details
Details of the condition or symptoms which has resulted in this claim (please be specific).
Have you claimed for this condition previously?
When did you first have symptoms?
When did you first seek medical advice?
Yes
No
Provide details of the investigation/treatment performed/to be performed.
Date of admission
Date of discharge
/
/
/
/
AIACL-003-04
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