IFRC

1IFRC
2Costs informations
3Nature of medical cost
4Obligatoirement des factures
5You have almost completed the form

IFRC

Who are you?

Employee (Geneva Office)

Delegate

Retired

Relationship

Myself

Spouse / secondary dependant

Child

Title

Mr.

Ms.

Name of employee/retiree/delegate

First name

Email address

Please use your business email address (@ifrc.org)

Identification Number

Patient informations:

Title

Mr.

Ms.

Patient's name

First name

Date of birth (date/month/year)

Year of treatment

Costs informations

Does the invoice(s) relate to a hospitalization?

Yes

Admission date

Discharge date

Name of the hospital

Does this claim relate to an accident?

Yes

In case of injury claim, please contact Miss Francine Golay or your HR Department

Please give us a short description, including how, where and when the accident occured

Please describe the nature of your injury

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.

Number of invoices

Invoice 1

Country

Currency

Amount

Nature of medical cost

Nature of medical treatment

Invoice 2

Country

Currency

Amount

Nature of medical cost

Nature of medical treatment

Invoice 3

Country

Currency

Amount

Nature of medical cost

Nature of medical treatment

Invoice 4

Country

Currency

Amount

Nature of medical cost

Nature of medical treatment

Invoice 5

Country

Currency

Amount

Nature of medical cost

Nature of medical treatment

Invoice 6

Country

Currency

Amount

Nature of medical cost

Nature of medical treatment

Invoice 7

Country

Currency

Amount

Nature of medical cost

Nature of medical treatment

Invoice 8

Country

Currency

Amount

Nature of medical cost

Nature of medical treatment

Invoice 9

Country

Currency

Amount

Nature of medical cost

Nature of medical treatment

Invoice 10

Country

Currency

Amount

Nature of medical cost

Nature of medical treatment

Invoice 11

Country

Currency

Amount

Nature of medical cost

Nature of medical treatment

Invoice 12

Country

Currency

Amount

Nature of medical cost

Nature of medical treatment

Obligatoirement des factures

Would you like to attach documents?

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.

I agree to conditions of data protection.

Form UUID

Checksum

ThankYou-page URL

Form sub-type

Hidden controls

Client context

Agency ID

Interest ID

Server context

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