Overseas Student Health Cover - Claim Form
ADVERTISEMENT
1
2Overseas Student
Health Cover
Claim form
Please complete both sides of this application in CAPITAL letters. Post or fax the application to Allianz Global Assistance OSHC
with all required attachments.
Policy holder details
please tick if your address has changed
Policy number (must be provided):
(Please attach a copy of your valid student visa)
Type of policy:
Standard
Essential
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
Allianz Global Assistance
If accounts are unpaid, payments will be made directly to the provider. Please direct any enquiries from the provider to
.
•
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 from 1 January 2012) 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 ‘Student’ section of the website or call
our Members Services on 13 OSHC (13 6742).
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 student visa?
yes
no
Please Note: You are required to provide a copy of your current student visa when making a claim.
Total amount of all claims lodged in this instance: $
PLEASE TURN OVER AND COMPLETE PAGE 2 OF THIS FORM.
1
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business