Claim application
Report a claim | Health insurance | If Insurance
Before the claim application submission:
1) check which medical costs are payable and which not
2) ask the policy number from your employer
3) take a picture or scan medical receipts (every receipt separately)
4) find your bank account number
Policy number
Required
Required
Policy number {{ model.policyNumber }}
Your employer (Policyholder) {{ model.policyHolderName }}
Recipient of treatment
Required
Person who received medical service
Required
Required
Required
Required
Check the phone number
Check the phone number
Required
Check the e-mail address
Did you receive medical service? Yes No
Person who received medical service
Name {{ sufferer.name }}
Surname {{ sufferer.surname }}
ID code {{ sufferer.code }}
Phone number {{ sufferer.phoneNumber }}
Email {{ sufferer.email }}
Medical services
Please enter every receipt separately
Required
Required
Date not valid
Date can not be in the future
Date cannot be in a past
Required
Required
Check the number. Correct is: 100 or 100.20
Medical receipt or document {{ fileUploadProperties.pendingFilesCount + fileUploadProperties.uploadedFilesCount }} / {{ fileUploadProperties.maxFilesCount }}
Required
Service description {{ service.descriptionName }}
Date of receipt of the medical service {{service.dateOfService | hkDate }}
Service provider {{ service.providerName }}
Service provider {{ service.providerOther }}
Sum of the service fee € {{ service.sumOfFee | number:2 }}
Medical receipt or document
Comments
{{ model.receivedServices.comments }}
Compensation
I request the compensation
Required
Required
Required
Required
Required
Required
Account number is not correct
Required
Required
Name {{ model.compensation.recipient.name }}
Surname {{ model.compensation.recipient.surname }}
ID code {{ model.compensation.recipient.code }}
Name {{ model.compensation.recipient.name }}
Company reg. code {{ model.compensation.recipient.code }}
Bank {{ model.compensation.bankName }}
Account number (IBAN) {{ model.compensation.bankAccountNumber }}
My Data
Required
Required
Required
Required
First name {{ model.submitter.name }}
Last name {{ model.submitter.surname }}
Phone number {{ model.submitter.phoneNumber }}
E-mail {{ model.submitter.email }}
Privacy notice
Advantages:
-
Ninety percent of our clients evaluate our claims handling process as ‘good’ or ‘very good’.
- In case of questions call us 24/7 by phone777 1211.