2018 +Generali+Claim+form EN+ (Legal+rev) +-+171017

CLAIM FORM
(GROUP INSURANCE)
Insurance card number: ………………………………………………Policy owner (Company name): ..............................................
I. PERSONAL INFORMATION
CLAIMANT
Full name: .................................................................................................................... D.O.B: ………../………../ .........................
ID/Passport:............................................................................. Issue date: ……. /……. /………. Place of issue: ..........................
Tel No.: .................................................................................... Email: ...........................................................................................
Relationship with Insured person: ……………………………………………… ................................................................................
INSURED PERSON (a person asks to be covered under this policy)

 Employee  Employee’s relatives
Full name: ………………………………………………………….D.O.B ………../………../………..  Male  Female
ID/ Passport:.............................................................………… Issue date: ……. /……. /………. Place of issue: ..........................
Tel No: ......................................................................…………Email: ............................................................................................
Address: ................................................................................................................ …………..Province: ......................................
II. CLAIM’S INFORMATION
Claim type:
 In-patient  Out-patient  Dental care  Maternity
 Total permanent disability
 Death: Time of death ………. Date of death……./……./……….Cause of death: ....................................................................
Death place: ………………………………………..………………… at  Home  Medical center  Others
The date of first symptoms: ………../………. /…………
The date of first Consultation/Clinical test/treatment: ………./……../………, at medical center:........................................................
Treatment history (kindly provide medical records)

Treatment place Examination Discharge date Diagnosis
………………………….…….. date/Admission date …………………….. …….…………………………..
…………………………….….. ……………………… …………………….. …….…………………………..
…………………………….….. ……………………… …………………….. …….…………………………..
………………………
 Cause of accident: Time of accident………, date……./……./……… Place of accident: …… ........ ... Province: ......................
III. PAYMENT INFORMATION (BANK TRANSFER PAYMENT)
Bank account name:............................................................. Bank account number: ..................................................................

Bank name: .......................................................................... Branch name: ...............................................................................
Transaction office: ...........................................Address: ............................................................... Province: ..............................
Claim documents Accounting documents
 Discharge certificate  Receipt/ Invoice Receipt/Invoice No. Amount (VND)

 Surgery certificate (please specify on next column)
 Medical book/ medical report  Incident/accident report
 Clinical test result  Death certificate
 Prescription  Others
 Sick leave certificate ………………………………………..
Total
IV. COMMITMENT REGARDING TO THE FOREIGN ACCOUNT TAX COMPLIANCE ACT (FATCA)
Please check the appropriate box below (if any):

I am/We are citizen(s) or long-term resident(s) of the United States (U.S.) 
I/We have some aspects related to U.S. including: having U.S. birth certificate/U.S. home 
address/ U.S. telephone number.
I/ We have U.S. tax filing obligations 
In case the claimant is citizen/organization of U.S. or has some aspects related to U.S. and has U.S. tax filing obligations in accordance with
the foreign account tax compliance act (FATCA), please submit W9/W8 form as per Generali staff’s instruction.
V. COMMITMENT AND AGREEMENT
I/We:
(a) Hereby certify that all the information provided on this form along with the documents enclosed are complete and accurate to the
best of my/ our knowledge and ready to provide other documents for claim processing if required.
(b) Give permission and authorize any organization, company or individual who has knowledge of the occupation, health, medical
history, insured event of insured person to provide Generali or Generali ‘s representative any information required,
(c) Give Generali permission to use my/our address, telephone number, email in order to provide information required to complete the
assessment of this claim.
(d) In case violating the insurance policy, I/we ensure to refund the excess amount or the amount is not covered by the insurance
policy which Generali already paid.
CLAIMANT COMPANY’S CONFIRMATION

(Signature and full name) (Signature and stamp)
Full name: …………………………………………………… Full name: ……………………………………………………

Date: ……..…/……..…../………. Date: ……..…/……..…../……….
(Applied for death claim)

2018 +Generali+Claim+form EN+ (Legal+rev) +-+171017

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CLAIM FORM

INSURED PERSON (a person asks to be covered under this policy)

II. CLAIM’S INFORMATION

Treatment history (kindly provide medical records)

III. PAYMENT INFORMATION (BANK TRANSFER PAYMENT)

Bank account name:............................................................. Bank account number: ..................................................................

Claim documents Accounting documents

 Discharge certificate  Receipt/ Invoice Receipt/Invoice No. Amount (VND)

Please check the appropriate box below (if any):

V. COMMITMENT AND AGREEMENT

CLAIMANT COMPANY’S CONFIRMATION

Full name: …………………………………………………… Full name: ……………………………………………………

(Applied for death claim)

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