ACCIDENT AND ILLNESS CLAIM FORM

Name of Client Company: _________________________

Employee Number: ______________________________ Mayfair ID Number Claimant: _____________________________
Your E-mail ID___________________________________ Mayfair ID Number Patient: ______________________________

1) Name of Patient: ______________________________________________ Date of Birth _____/_____/____ Sex: Male/Female

2) Name of Claimant: _____________________________________________ Date of Birth _____/_____/____ Sex: Male/Female

PLEASE READ THIS CAREFULY

1.This form is to be used when filing a claim for reimbursement of Medical Expenses and MUST be completed by the Insured in full.
2.Fully itemized bills including Claimants Name, Nature of Illness/Injury, and diagnosis must be included with this claim form.
3.This form must be signed and dated in all applicable sections.
4.This form and all attached bills must be submitted as Email Scan copies.
5. Complete Bank details needed (Incorrect details may lead to short transfer bank transaction charges may be applicable.)
INCOMPLETE CLAIM FORM MAY DELAY REIMBURSEMENT PROCESS

HELPFUL HINTS
1. When you are submitting expenses for more than one family member, please use a separate claim form for each person.
2. It is suggested that you make copies for your own use before you submit the original bills if so requested for the Claims Team.
3. Prescription Drugs-Bills must show the patients name , date of service, prescription number amount paid, name, strength & quantity of drug ,
the name and address of the pharmacy.
4. If the provider needs to be paid please provide providers bank details

3) Current Residence Address: ____________________________________________________________________________

Daytime Phone Number: __________________________Mobile Phone Number: ___________________________________
4) Permanent Address (In Home Country):
______________________________________________________________________________________________________
5) If Accident, provide details, i.e., how when and where accident occurred
_______________________________________________________________________________________________________
6) If Illness, advise when and where symptoms first occurred and nature of illness___________________________________
7) Exact diagnosis: _______________________________________________________________________________________
a) If Maternity Related (Date of confirmation of pregnancy/ Estimated date of delivery/ Any complications foreseen)
_______________________________________________________________________________________________________
8) Consulting Physicians Name: ___________________________________________________________________________
Address: _________________________________________________________Phone Number: _________________
9) Has Mayfair assistance / Sevencorners been contacted with regards to this illness. Yes No
10) Have you ever been treated for this Illness before? Yes No
.If Yes, when? _______________________________________
a) Have you been completely cured of the above diagnosis Yes No .
11) Please advise names of any prescription medications you are presently taking: _________________________________________
12) Indicate other Health Insurance coverage, include name, address, policy number and certificate number of Insurer: __________
_____________________________________________________________________________________________________________
Any Other Information that you would like to provide: _______________________________________________________________
_____________________________________________________________________________________________________________

HOW TO SUBMIT THE CLAIM FORM

Please e-mail Scan copies of the completed claim form along with all supporting documents / reports/ bills/ invoices to Mayfair.claims@ihmsworldwide.com
ORIGINALS WOULD BE REQUESTED ON A CASE TO CASE BASIS
Postal Address: INTERNATIONAL HEALTHCARE MANAGEMENT SERVICES PVT LTD.
Mayfair Claims Department# 459, 2nd Floor, Service Road, Off Outer Ring Road, Teachers Colony, Venkatapura, Bangalore - 560 034 INDIA.

Details of Expenses Claimed

AILMENT

Dates of Treatment

Service provided

Currency and amount paid

RECEIPTS No.

SETTLEMENT DETAILS:
Bank details (For Wire Transfers):
A) Beneficiary Name: _________________________________________________
B) Bank Name: ______________________________________________________
C) Bank Address: ____________________________________________________
___________________________________________________________________
___________________________________________________________________
D) IBAN number (Europe) ______________________________________________
BSB Code (Australia) ________________________________________________
Transit/Sort Code (Canada, South Africa) ________________________________
IFSC Code (India) __________________________________
Clabe number (Mexico) _____________________________
Bank Routing code/sort code/branch code (Indonesia/Malaysia/ Singapore) ___
___________________________________________________________________
E) Account number: ____________________________________
F) Swift code (mandatory) ________________________________
G) Your account currency ________________________________
Address details (if requesting cheque payment only):
A) Beneficiary Name: _________________________________________________
B) Address with Post code: ____________________________________________
__________________________________________________________________
___________________________________________________________________
C) Your account currency __________________________________
CHEQUES ARE SENT OUT BY POST AND POSTAL DELAYS ARE OUT OF OUR CONTROL
The furnishing of this form, or its acceptance by the Company, must not be construed as an admission of any liability on the Company, nor a waiver of any of the conditions of the
insurance contract. Any person who knowingly and/or with intent to injure, defraud, or deceive an insurance company or other person files a statement of claim containing false,
incomplete or misleading information, may be guilty of insurance fraud and subject to criminal and substantial civil penalties.

I, the undersigned authorize any hospital or other medical-care institution, physician or other medical professional, pharmacy, insurance support organization, governmental agency,
group policyholder, insurance company, association, employer or benefit plan administrator furnish to the Claims Administrator named above or its representatives, any and all
information with respect to any injury or illness suffered by, the medical history of, or any consultation, prescription or treatment provided to, the person whose death, injury,
illness or loss is the basis of claim and copies of all of that persons hospital or medical records, including information relating to mental illness and use of drugs and alcohol, to
determine eligibility for benefit payments under the Policy Number identified above. I authorize the group policyholder, employer or benefit plan administrators to provide the
Claims Administrator named above with financial and employment-related information. I understand that this authorization is valid for the term of coverage of the Policy identified
above and that a copy of this authorization shall be considered as valid as the original.
I understand that I, or my authorized representative, may request a copy of this authorization.

In addition, I hereby certify that the above information is true and correct to the best of my knowledge and belief.
_______________________________________________________
Signature of Claimant or Parent, If Claimant is a Minor

______________________
Date