IMPORTANT INSTRUCTIONS TO COMPLETE YOUR CLAIM: 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section A, filling in your Policy/Member Information. Enter the Patient Name, Policyholder Name, Policy Number, and Member Number. Ensure your contact details are accurate.
3. Provide your bank account information for reimbursement. Fill in the Bank Name, Address, Account Name, Sort Code, Account Number, IBAN Code, and BIC (Swift) Code.
4. Move to Section B. Answer questions regarding illness or accident details thoroughly. Include dates and descriptions as required.
5. In the Declaration section, confirm that all information is true by signing and dating the form.
6. If applicable, have your physician complete Section C with their observations and signature.
7. Review all sections to ensure completeness before submitting your claim along with any required documents.

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