Form Cf 11/04 - Claim Form. printable pdf download

Claim Form.

Allianz Worldwide Care

To help us provide you with a fast and efficient service, we kindly ask you to note the following:

•

A fully completed form will speed up the assessment and payment of your claim

•

All relevant original invoices must be attached. Unfortunately, photocopies, receipts and credit card slips cannot be

accepted. We recommend that you keep copies of all documents submitted, should you require them at a later date

•

A separate claim form is required for every patient and each medical condition

•

Finally, we kindly ask that you complete this form in BLOCK CAPITALS and post to the address below within 6

months after the end of the insurance year. Beyond this time we are not obliged to settle the claim

1. Policyholder details.

Insurance number

Title

Surname

First name(s)

Correspondence address

Phone no. daytime

Evening

Fax

2. Patient details.

Title

Surname

First name(s)

d d

m m

y y

Date of birth

Is this claim related to an accident?

Yes

(dd/mm/yy)

3. Payment details.

Option 1

Payment to Policyholder/Insured

Payment to be made in: Invoice currency

Other currency

(please specify)

Preferred payment method: Cheque

Bank transfer

(please fill in bank details)

Name of bank account

Account no./IBAN

Sort/branch code

Swift code

Bank name

Bank address

Option 2

Payment to Provider of Medical Service (e.g Hospital, Specialist, MRI)

Please tick if direct billing has been previously agreed with Allianz Worldwide Care

4. Patient signature and release of medical records.

I certify that to the best of my knowledge, this claim form does not contain any false, misleading or incomplete

information. I understand that in the event that this claim is found to be fraudulent in whole or in part, the policy

will be invalidated and I will be liable for prosecution. In respect of any medical claim, I hereby authorise my

medical practitioner, health professional or other relevant medical establishment to provide any health details

or medical records that may be requested by Allianz Worldwide Care Limited or their appointed representatives.

If a minor was treated, a parent or guardian should sign this section.

d d

m m

y y

Patient signature

Date

(dd/mm/yy)

Allianz Worldwide Care Limited, Claims Department, 20D Beckett Way,

Park West Business Campus, Nangor Road, Dublin 12, Ireland.

Helpline: +353 1 630 1301 Fax: +353 1 630 1306 E-mail:

Form Cf 11/04 - Claim Form.

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