IFCR

IFRC

Employee (Geneva Office)
Delegate
Retired
Myself
Spouse / secondary dependant
Child
Mr.
Ms.
Please use your business email address (@ifrc.org)

Patient informations:

Mr.
Ms.

Costs informations

Yes
No
Yes
No
In case of injury claim, please contact Miss Francine Golay or your HR Department

Nature of medical cost

If your claim form contains invoices from different years it will be refused!
Do not add up invoices in one line "Nature of medical cost" needs to be precise invoices more than one year old (invoice date) will not be reimbursed

Please attach copies of invoices and medical prescriptions related to this claims (scanned PDF File only). The original documents must be stored 1 year in case of control of the insurance.

Invoice 1

Invoice 2

Invoice 3

Invoice 4

Invoice 5

Invoice 6

Invoice 7

Invoice 8

Invoice 9

Invoice 10

Invoice 11

Invoice 12

Obligatoirement des factures

You have almost completed the form

The Undersigned hereby authorizes the insurance company AXA Insurance Ltd to obtain and make use of the data required to process the claim, assigning such tasks to third parties where necessary. The Undersigned expressly releases the doctor/psychotherapist/physiotherapist/chiropractor involved from his or her obligation to maintain confidentiality in dealings with the insurance company AXA Insurance Ltd with regard to any and all questions relating to the insured event. The insurance company AXA Insurance Ltd is likewise authorized to obtain from the official bodies concerned any information required and to consult official dossiers and medical records insofar as they relate to the claim submitted. The insurance company AXA Insurance Ltd undertakes to treat as confidential any information it receives.
I certify that the contents of my claim are true. In case of fraud, I am exposed to possible sanctions from my employer and/or insurance company.
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