Cross-Border Medical Insurance Claim Form
Policyholder Information
Name
Date of Birth
Policy Number
Contact Number
Email
Address
Patient Information
Name
Relationship to Policyholder
Date of Birth
Country Where Treatment Was Received
Treatment Details
Date of Treatment
Name of Hospital/Clinic
Country
Reason for Treatment/Diagnosis
Claim Details
Total Amount Claimed (Currency)
Currency
Description of Expenses
Bank Account Details (for reimbursement)
Account Holder Name
Bank Name
Bank Account Number/IBAN
SWIFT/BIC Code
Bank Address
Declaration
I confirm that to the best of my knowledge, the information provided is accurate and complete.
Date
Signature