Insurance Claim Report

POLICY NUMBER *

12 digits that can be found, for example, on the health insurance card that we sent you when arranging insurance.

POLICYHOLDER'S NAME AND SURNAME *

Křestní jméno

Druhé jméno

Příjmení

INSURED'S IDENTITY CARD OR PASSPORT NUMBER *

TELEPHONE *

EMAIL *

DATE OF CLAIM *

CAUSE OF THE CLAIM *

A DETAILED DESCRIPTION OF THE CLAIM *

MEDICAL FACILITY, WHERE WAS THE EXAMINATION PROVIDED *

REQUIRED DOCUMENTS: MEDICAL REPORT & ORIGINALS OF RECEIPT

Click or drag files to this area to upload. You can upload up to 10 files.

Click or drag and drop all necessary medical report(s) and original(s) of receipt (max. 8 MB / file, max. 10 files)

INSURANCE BENEFIT SEND ON BANK ACCOUNT NUMBER *

GDPR *

Health Insurance for Foreigners – Insurance Claim Report