International Long-Term Care Services Claim Form
Claimant Information
Full Name
Date of Birth
Address
Contact Number
Email
Policy Number
Provider Information
Facility/Provider Name
Provider Address
Provider Contact Number
Claim Details
Date of Admission
Date of Discharge
Type of Services Received
Description of Services
Total Amount Claimed
Bank Information (for Reimbursement)
Bank Name
Account Holder Name
Account Number / IBAN
SWIFT/BIC Code
Bank Address
Declaration & Signature
Signature
Date