Policy number
Date of birth
First name
Surname
Country of residence
Telephone number
Email
First name
Surname
Date of birth Gender: Male Female
Country of treatment (if outside country of residence)
In what country did the treatment take place?
Duration of stay abroad
Reasons for stay abroad:
Holidays
Business trip
Medical treatment
1 POLICYHOLDER’SDETAILS
2 PATIENT’SDETAILS(IFDIFFERENTFROMPOLICYHOLDER)
DD/MM/YYYY
DD/MM/YYYY
CLAIMFORM
Please complete this form in BLOCK CAPITALS
COUNTRY CODE AREA CODE
Option 1: Payment to medical provider* (e.g. hospital, specialist)
The bank details requested below are not required for this option.
Option 2: Payment to policyholder
Payment method: Bank transfer**
Please specify the currency you would like to be reimbursed in (and ensure that your bank account supports it)
Name of bank account holder as shown on your bank statement
Account number
IBAN (where required)***
Sort/branch code BIC/Swift code***
Name of bank
Bank address
If you are aware of any additional information required in order to process international transactions within your country (e.g. agency code, tax ID), please list it here:
Swift code of intermediary bank (where applicable)
* If you have not already paid the medical provider.
** For bank transfer, please provide bank details.
*** If your bank is within the EU, or if your specific country requires an IBAN (e.g. Qatar, Saudi Arabia, Angola, Tunisia, Turkey), please supply both your IBAN and BIC/Swift code to facilitate the payment of your claim.
3 PAYMENTDETAILS
Please EITHER tick option 1 OR tick and complete option 2.
Please complete all parts of the following table with the details of each invoice/receipt. Please note that for costs incurred in China, you must submit a FaPiao
invoice. If your invoice/receipt does not include the diagnosis/medical condition, you must give this information below. If there is insufficient space in the table
below, please provide details on a separate page.
In what country did the treatment take place?
Claims related to an accident or injury:
Is this claim related to an accident/injury? Yes No
If yes, please complete the following:
Date of accident/injury
Details of the accident/injury
Do you have any other insurance policy (e.g. Travel insurance)? Yes No
If yes, please provide the following:
Name of the insurer
Policy number
Was the accident/injury caused by a third party? Yes No
If yes, please complete the following:
Name of the third party
Name of the third party insurer
Third party policy number
Please send us a copy of the police report if available to: [email protected]
4 CLAIMDETAILS
DD/MM/YYYY
Description of expense/
treatment
Diagnosis/medical condition Provider’s name Amount
charged
Currency Have you paid
this bill?
Yes
No
Yes No
Yes No
Yes No
Yes No
Total Amount of Expenses
(Please note that the total displayed here is only accurate when all invoices are issued in the same currency.
If you are claiming costs in dierent currencies, please ignore the total amount displayed)
0.00
Doctor’s signature
Date
Indicate type of condition: Acute Chronic Acute episode of chronic
Please provide full details of the symptoms or medical condition requiring treatment:
ICD9/10 code/DSM-IV
Details of the symptoms/medical condition
On what date did the patient first present these symptoms to you?
On what date would the first onset of symptoms have been apparent to the patient?
Has the patient suffered from this condition previously? Yes No
If Yes, when?
Are you aware of any treatment given for this or any related illness in the past?
Yes No
If Yes, please provide details
Is it likely to re-occur? Yes No
Does it need rehabilitation? Yes No
Is it permanent? Yes No
Does it need long-term monitoring, consultations, check-ups, examinations or tests? Yes No
Applicable to cases of pregnancy only:
Estimated date of delivery
Is birth of a single baby expected? Yes No
If twins/multiple babies are expected, is the pregnancy a result of medically assisted reproduction? Yes No
If Yes, please provide further details
Applicable to dental treatment claims only:
Was the patient suffering from dental pain at the time he/she visited you for treatment?
Yes No
Please sign and authenticate with an official stamp.
Name of doctor/specialist
Qualifications/credentials
Name of hospital/clinic
Address
Telephone number
Fax number
Email
Applicable to physiotherapy/psychotherapy claims only. Please provide full referral details:
Name of referring doctor
Telephone number
Date of referral
Official stamp of medical provider
5 MEDICALPROVIDER’SDETAILS
6 MEDICALDETAILS
Sections 5 and 6 are to be completed by the treating doctor unless the information is detailed in the supporting documentation
(e.g. receipts or invoices).
DD/MM/YYYY
COUNTRY CODE
COUNTRY CODE
COUNTRY CODE
AREA CODE
AREA CODE
AREA CODE
DD/MM/YYYY
DD/MM/YYYY
DD/MM/YYYY
DD/MM/YYYY
DD/MM/YYYY
The processing of personal data is essential to the transaction of insurance business. In the processing of personal data, we comply with the Swiss Data Protection
Act (DPA). We store data electronically or physically in compliance with the applicable and relevant legal provisions.
References to information include personal information given by you to us, in your Application, Claim or Treatment Guarantee Form and/or supporting
documents/information we collect in connection with products or services we provide.
Uses: The personal data processed by us include data relating to and for the purposes of preparing quotations, underwriting policies, collecting premium, paying
claims and for any other purpose which is directly related to administering policies in accordance with the insurance. We may use third parties to process data on our
behalf. Such processing, which may take place outside the European Economic Area (EEA), is subject to contractual restrictions regarding confidentiality and security
in line with Data Protection obligations. We also process personal data in connection with product enhancements, as well as for our own marketing purposes.
In order to offer affordable comprehensive insurance cover, our services may partly be provided by legally independent firms both domestically and abroad.
Sensitive data: We need to collect sensitive data relating to you (e.g. health details), to assess insurance terms and/or administer claims.
7 DATAPROTECTIONANDRELEASEOFMEDICALRECORDS
It is your responsibility to retain any original supporting documents (e.g. medical receipts) when you send us copies, as we reserve the right to request original supporting documents up to 12 months after
each claim has been settled, for auditing purposes. We also reserve the right to request a proof of your payment (e.g. bank or credit card statement) in respect of your medical receipts. We advise you to
keep copies of all correspondence with us as we cannot be held responsible for correspondence that does not reach us for any reason that is outside of our reasonable control.
As the claimant, I hereby authorise
to act on my behalf and on behalf of any dependants named on this form (where applicable), in relation to the administration of this claim. This may include the
disclosure of sensitive medical information.
INSERT NAME OF THIRD PARTY
8 THIRDPARTYAUTHORISATION
The Underwriter of your VVG insurance is AWP P&C S.A., Saint-Ouen (Paris), Wallisellen Branch (Switzerland), the Swiss Branch of AWP P&C S.A., Saint-Ouen, France, a limited company governed by the
French Insurance Code. Registered in France: No. 519 490 080 RCS Paris. Swiss Branch registered in Zurich, registered No.:CHE-115.393.016, address: Hertistrasse 2, 8304 Wallisellen.
KPT Krankenkasse AG, Wankdorfallee 3, CH-3000 Bern 22, registered BAG Nr. 376. KPT provides administration services inside Switzerland.
AWP Health & Life SA, acting through its Irish Branch, is a limited company governed by the French Insurance Code. Registered in France: No. 401 154 679 RCS Bobigny. Irish Branch registered in the
Irish Companies Registration Office, registered No.: 907619, address: 15 Joyce Way, Park West Business Campus, Nangor Road, Dublin 12, Ireland. AWP Health & Life SA, acts as the reinsurer of the VVG
policies, provides administration services and technical support outside Switzerland. Allianz Partners and Allianz Care are registered business names of AWP Health & Life SA.
Claimant’s signature
Claimant’s printed name
Date
DD/MM/YYYY
FRM-CF-Switz-EN-0920
Please send your fully completed Claim Form(s) with any supporting invoices/receipts
(credit card slips cannot be accepted) by:
Email to: claims@allianzworldwidecare.com
Fax to: + 353 1 645 4033
Post to: Claims Department, Allianz Care, 15 Joyce Way, Park West Business Campus,
Nangor Road, Dublin 12, Ireland
Important – please check the following:
All receipts, invoices and prescriptions are included.
The Claim Form is completed in full.
The declarations are signed and dated.
The diagnosis has been conrmed and is stated either on the Claim Form or on the invoices.
Your contact details are still correct (if they have changed, please let us know on the Claim Form).
Did you know...
...that most of our members nd that their queries are handled quicker when they call us?
If you have any queries, please contact our Helpline on: + 353 1 630 1301 or email: client.services@allianzworldwidecare.com
For our latest list of toll-free numbers, please visit: www.allianzcare.com/toll-free-numbers
Patient’s signature
Date
Disclosure: We may share your information with our agents, members of the Allianz Group, reinsurers, other insurers and their agents, previous domestic and
foreign insurers, service providers, any intermediary acting on your behalf or governing/regulatory bodies (of which we are a member or by which we are
governed). In certain circumstances, we may use private investigators to investigate a claim you have submitted.
Retention: We are obliged to retain your records for six years from the date the insurance relationship ends. We will not retain your data for longer than
necessary and will hold it only for the purposes for which it was obtained.
Representation and Consent: By signing this form you confirm that you have the authority to act on behalf of your dependants in respect of all personal
information you provide to us, and that you consent to the disclosure, processing, usage and retention of this information in relation to yourself and on behalf of
your dependants.
Access: You have the right in accordance with the DPA to request and receive a copy of your personal data held by us and may also request rectification of incorrect
data. If you wish to do this, please write to the Data Protection Officer at the address provided on this form or via [email protected].
Call recording: Calls to our Helpline will be recorded and may be monitored for training, quality and regulatory purposes.
I certify that to the best of my knowledge, this Claim Form does not contain any false, misleading or incomplete information. I understand that if this claim is found
to be fraudulent, in whole or in part, the contract will be cancelled from the date the fraud is discovered and I may be liable to prosecution.
I agree to waive any rights that I may have to medical secrecy/confidentiality in respect of my medical information and I authorise my medical practitioner, health
professional or other relevant medical establishment to provide relevant medical information about me, if requested by my Insurer, to its medical advisers or its
appointed representatives, or to any third party expert(s) in case of disputes, subject to any legal restrictions which may apply.
If a minor was treated, a parent or guardian should sign and date this section.
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