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Submit claim Expat - medical expenses

* These fields are mandatory. You will see a Dutch message 'Dit veld is verplicht.' if you leave it empty.

You can use this form to submit a claim for medical expenses. If you have a number of invoices, then you must claim each one separately.

1

Claimant

Who can claim? Only an insured member mentioned on the policy schedule.

2

Who incurred the expenses?

For which insured member?

3

Treatment

Information concerning the treatment

Warning! Please don’t fill any personal medical information in with regards to your treatment or medicine.

Please upload a clear legible invoice specifying which treatment you received in jpg of .pdf form (maximal 1 MB). This will ensure that we can deal with your claim in a timely manner.

Upload maximum of 5MB.
Upload maximum of 5MB.
Upload maximum of 5MB.
4

Beneficiary

Who should we reimburse?

By completing and submitting this claim, you declare that you have taken note of the contents of this web form and that the answers you have provided are correct and complete. If the invoices and information relate to a co-insured person, you declare that you are authorized to represent this co-insured person and that the co-insured person has given you permission to submit these invoices and provide the associated information, to the extent necessary. (NB: permission is not required if it concerns children of the main insured up to and including the age of 15.) You declare that you will send this claim form and any further information to be provided to the company to determine the extent of the damage and the right to benefits. All data provided can be processed in the database of the Central Information System Foundation of insurance companies operating in the Netherlands. The privacy regulations of the CIS Foundation apply to the registration. See www.stichtingcis.nl.

Important! It is very important that you make this claim correctly and completely. If you do not do this, this could lead to, among other things, the benefit being reduced or even being rejected. Fraud and other forms of crime cost honest policyholders money. We are alert to this in your and our interests. In the event of fraud and crime, we do not reimburse expenses, and this may lead to the termination of the insurance(s). We will then register your personal data in the signaling system (CIS) that all insurers use. We can also report this to the police or the Public Prosecution Service.