Trafalgar  
International Ltd

Health and Hospitalisation Insurance
Claim Form

Please ensure that your claim form is completed in full and returned as soon as possible.  Please note that Insurers are not responsible for any fees incurred in the completion of this form and the issuing of this claim form is in no way an admission of liability.

GENERAL INFORMATION	
Group name: (if applicable)		
Policy number:		
Policyholder:		
SECTION A - PERSONAL INFORMATION	
Surname:		
First name and initials:		
Address:		
Date of Birth:		
Telephone:		
Fax		
e-mail		
SECTION B - CLAIMS DETAILS	
Date symptoms first noticed:		
Please describe condition and how it occurred if an accident.		
Have you suffered from this condition previously? - if so, when?:		
Have you made a previous claim for this condition? - if so, when?:		
Name and address of usual Medical Practitioner:		
Name and address of attending Medical Practitioner:		
Was a third party responsible for your injury? if yes, please provide details on a separate sheet.		
Do you hold any other insurance under which you could claim?  If yes, please provide details on a separate sheet.		
SECTION	C AMOUNT CLAIMED (SUB TOTALS OF EACH)	
Currency:		
Consultations:		
Medication:		
Hospitalisation:		
Other:		
Total Claimed:		
How do you wish settlement to be made:	Cheque		Bank Transfer		
In which currency would you like settlement?		
Bank Details: (Full name, address & account number)		
SECTION D - DECLARATION	
I declare that all information, to the best of my knowledge, provided on this claim form is truthful and correct.
I also understand that this declaration gives permission to Insurers and their appointed representatives to approach any third party for information required to complete their assessment of this claim including, but not limited to, my current and previous Medical Practitioners.  (If patient is under 18 years, parent or guardian must sign)	
Patient's signature:		
Date:		
SECTION D (ii)	
This section must be completed by the policy holder or, if the insured is under a company/corporate scheme, it is necessary for the following section to be completed by an authorised official	
Name:		
Position:		
Signature:		
Date:		
SECTION E - MEDICAL - TO BE COMPLETED BY THE MEDICAL PRACTITIONER	
For all out-patient claims under HKD1,500.00, the original receipt, diagnosis and breakdown of costs will suffice.  However, this section must be completed IN FULL by the Medical or Dental Practitioner for ALL claims over HKD1,500.00. Your assistance would be appreciated by: 
•	Ensuring the relevant sections are completed in full. 
•	Using BLOCK CAPITALS.  This will ensure prompt assessment of the claim.  
PLEASE NOTE: Any fee for completion of this form is the responsibility of the patient.	
Patient’s surname:		
Patient’s first name and initials:		
Condition requiring treatment:		
Underlying cause(s):		
Date of first consultation with any Medical Practitioner for this condition:		
Name and address of referring doctor:		
How long prior to this date would condition, or symptoms, have been apparent to the patient?		
Has this or any similar condition existed previously?		
Likely period of treatment required:		
Please advise dates of previous consultations/treatment for this condition:		
Please detail any Pathology performed and attach results:		
Please detail any medication prescribed:		
SECTION F - - DENTAL - TO BE COMPLETED BY THE DENTAL PRACTITIONER	
Condition requiring treatment:		
Date of onset if accident:		
Composition of fillings/crowns (if applicable):		
Is treatment a routine check-up?		
SECTION G - DECLARATION - TO BE COMPLETED BY THE MEDICAL / DENTAL PRACTITIONER 	
Name:		
Address:		
Qualifications:		
Telephone:		
Fax no:		
E-mail:		
Signed:		
Official stamp:		
Date:		

Please return completed claim form to: 
Trafalgar International Limited
21st Fl. Vongvanij Complex, Building B,
100/63 Rama 9 Road, Huay Kwang,
Bangkok 10320, Thailand
Tel.: (66) 0-2645-1170; Fax: (66) 0-2645-1180
E-mail: insure@trafalgar-intl.com