Report a claim | Health insurance

Claim application
for health 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

Your employer (Policyholder)

Required

Policy number {{ model.policyNumber }}

Your employer (Policyholder) {{ model.policyHolderName }}

Recipient of treatment

Did you receive medical service?

Required

Person who received medical service

Name

Required

Surname

Required

ID code

Required

Phone number

Required

Check the phone number

Required

Check the e-mail address

I do not have 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

Service description

Required

Date of receipt of the medical service

Required

Date not valid

Date can not be in the future

Date cannot be in a past

Service provider

Required

Sum of the service fee €

Required

Check the number. Correct is: 100 or 100.20

Medical receipt or document {{ fileUploadProperties.pendingFilesCount + fileUploadProperties.uploadedFilesCount }} / {{ fileUploadProperties.maxFilesCount }}

File count limit reached. Some files has not been uploaded.

Upload one photograph or document at a time. To add the next one, click on the ‘Add the next medical treatment document’ button.

Required

Comments {{ model.receivedServices.comments != undefined ? model.receivedServices.comments.length : 0 }} / 1000

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

Compensation goes to

Compensation will go to me

Name

Required

Surname

Required

ID code

Required

Name

Required

Company reg. code

Required

Account number (IBAN)

Required

Account number is not correct

I do not know account number

Bank

Required

Bank

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

First name

Required

Last name

Required

Phone number

Required

E-mail

Required

I do not have e-mail address

First name {{ model.submitter.name }}

Last name {{ model.submitter.surname }}

Phone number {{ model.submitter.phoneNumber }}

E-mail {{ model.submitter.email }}

Privacy notice

If Insurance collects and processes personal data submitted with the claim and through the claims handling process according to the Privacy policy among other things: 1. to handle the claim and decide on the insurance indemnity; 2. to request information about the claim event (incl information concerning the state of health) from state and local government and other persons; 3. to contact you.

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.

Claim applicationfor health insurance