THE CREWSURE CLAIM FORM

HOW TO SUBMIT CLAIM FORM

Please e-mail Scan copies of the completed claim form along with all supporting documents / reports/ bills/ invoices to [email protected]

PLEASE READ THIS CAREFULY

1. Your Employer’s Crewsure policy will have a number of benefit sections. Please refer to your evidence of cover or your manager for details.
2. Fully itemized bills including Claimant’s 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. (Preferably in PDF)
5. If this claim form is being completed by your Employer or your legal representative – you may need to have their bank details. Please hand this form back to your
employer for them to complete. If you need to be directly reimbursed then please provide us your full Bank details needed (as incorrect details may lead to short
transfer; bank transaction charges may also be applicable.)
6. If you have any questions or concerns please call Mayfair on +91 80 30147200

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 and each medical condition.
2. It is suggested that you make copies for your own use before you submit the original bills if so requested for the Claims Tea m.

3. Prescription Drugs-Bills must show the patient’s 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 mention provider’s bank details

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Name of your Employer: Your Name (Employee) :

Certificate or group policy Number: _____________________________________Email address: _________________________________________

Date of Birth / / Gender: Male Female

Current Residence Address:

Daytime Phone Number: Mobile Phone Number:

Permanent Address (In Home Country): __________________________________________________________________

SETTLEMENT DETAILS:

Bank details (For Wire Transfer):

A) Beneficiary Name:
B) Bank Name:
C) Bank Address:
D) IBAN number (Europe/Bahrain/UAE) _____________________________________________

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
This claim is for (tick all that apply): Medical expenses in-patient  Medical expenses out-patient  Personal Injury 
Sick Pay &/or Loss of Wages  Death in Service  Loss or delay to baggage 

If you are claiming for a family member – please state their name: _________________________________________________________________

Date of Birth / / Gender: Male Female Relationship to you: Self Spouse Son Daughter

If caused by an Accident, provide details of how when and where accident occurred
_____________________________________________________________________________________________________________________

If Illness, advise when and where symptoms first occurred and nature of illness___________________________________________________

Exact diagnosis: ____________________________________________

Consulting Physicians – Name_________________________________________ Email Address: ___________________________________

Address: Phone Number:

Has Mayfair assistance been contacted with regards to this illness for cashless facility, Yes No
If Yes, has a Guarantee of Payment (GOP) been issued? Yes No

Have you ever been treated for this Illness before? Yes No If Yes, when?

Have you been completely cured of the above diagnosis Yes No

Please advise names of any prescription medications you are presently taking:

Indicate other Health Insurance coverage, include name, address, policy number and certificate number of Insurer_______________________

Any Other Information that you would like to provide: _______________________________________________________________________

For baggage claims – please enter your details here including the Date of Loss and circumstances as well as a copy of the airline or baggage
handlers report or in the event of theft a copy of the police incident number and/or report. Please also enclose a copy of the Master’s incident
report if whilst on board
_________________________________________ _____________________________________ ________________________________________

_________________________________________ _____________________________________ ________________________________________

Details of Expenses Claimed

Date of Treatment/
Details of Service/ Expenses Currency Amount Invoice/ Receipt No.
Service/ Expenses

The furnishing of this form, or its acceptance by certain underwriters at Lloyd’s, must not be construed as an admission of any liability by underwriters, 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 name d 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 person’s 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 certain information will also be shared with underwriters and their representatives. All information is kept strictly confidential.
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