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Travel Benefit
Arno Strauss
2021-02-05T09:03:17+02:00
1
Personal Details
2
Claim Details
3
Payment Details
Title
*
Mr
Mrs
Ms
Miss
Dr
Adv
Prof
Name
First
Last
ID or Passport Number
*
Cellphone
*
Email
*
Policy Number
*
To calculate your travel benefit we will require the details of the Hospital or medical facility relating to the admission as well as the residential address from where you or your spouse would have commenced travel.
Lastly we will also require confirmation of any additional accommodation expenses e.g Invoice form guest house
Residential Address
*
Street Address
Address Line 2
City
Province
Postal Code
Name of Hospital or Medical Facility
*
Address of Hospital or Medical Facility
*
Street Address
Address Line 2
City
Province
Postal Code
Date of admission
*
Day
1
2
3
4
5
6
7
8
9
10
11
12
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31
Month
1
2
3
4
5
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12
Year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
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1932
1931
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1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Please attach the account from the medical facility
*
Drop files here or
Select files
Accepted file types: jpg, gif, png, pdf, Max. file size: 10 MB, Max. files: 3.
Were there any accommodation expenses ?
*
Yes
No
Please attach the relevant receipt or invoice as it relates to the accommodation.
*
Drop files here or
Select files
Max. file size: 10 MB, Max. files: 4.
Bank Name
*
Account Type
*
Cheque/Current
Savings
Transmission
Account Number
*
Account Holder Name
*
Declaration and Submission
*
I hereby acknowledge and agree to the below :
I hereby declare that all details above as well as any supporting documentation supplied with this claim, are true and correct and I am aware that any non-disclosure or misrepresentation of any details may result in this claim being rejected or my policy being cancelled or voided from inception.
Δ
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