Sirago Claim Form

Sirago 申请索赔 Claim Form

Sirago Underwriting Managers (Pty) Ltd
在填写此表格前，请先准备好以下文件以拍照或上传：

Please have the following statements ready for upload:
1. 医疗保险索赔给付明细 medical aid statement
2. 医生账单 doctor's account
3. 医院账单 hospital account
4. 投保人已付款证明 proof of co-payment
若不上传以上相关文件会造成Sirago附加险索赔失败。

请允许此表格使用您手机的摄像头。

Please allow this form to access your smartphone's camera and/or photo library.
请注意以下保险公司说明：

Sirago Underwriting Managers（Pty）Ltd必须在发生任何可能引起索赔的90天内得到通知。如果没有以下文档，则不会考虑索赔：
•完整填写的签名索赔表（此表）
•所有帐户对帐单的副本（必须清楚）。
•医疗保险对账单，显示您的医保支付的所有金额。
•被保险人支付金额的付款证明。
•医院对账单/医保对账单，表明医疗保险要投保人自付额。
•癌症治疗计划（如适用）。
所有文件必须在医疗保险付款后90天内提交，才有资格获得付款。
所有保单条款均适用于提交的每项索赔。

Sirago Underwriting Managers (Pty) Ltd must be notified within 90 days of any occurance which may give rise to a claim. Claims will NOT be considered for assessment without the following documentation:
• A fully completed, signed claim form.
• Clear copies of all account statements.
• Medical Scheme statement showing all amounts paid by your Scheme.
• Proof of payment for amounts paid by the insured.
• Hospital account / Medical Scheme statement indicating co-payments imposed by the Medical Scheme.
• Cancer treatment plan if applicable.
All documents must be submitted within 90 days of payments by the Medical Scheme to qualify for payment.
All policy terms apply to each claim submitted.

Sirago Underwriting Managers (Pty) Ltd is an authorised Financial Services Provider (FSP:4710) Underwriting Agency for GENRIC Insurance
Company Limited (FSP: 43638). GENRIC is an authorised financial services provider and registered Short-term insurer.
顾问 Consultant Details *
主投保人资料

Principal Insured Details
姓名 Name *

名 First Name 姓 Last Name
ID/护照号码 ID Number / Passport *
出生年月日 Date of birth *

Year Month Day
Date Date Picker Icon
保单号码 Policy Number *
Insert policy number following MED
E-mail *
example@gmail.com
手机号码 Cellular Number *
入院日期 Admission Date *

Year Month Day
Date Date Picker Icon
出院日期 Discharge Date *

Year Month Day
Date Date Picker Icon
上传文件

Upload Documents
医疗保险索赔给付明细 medical aid statement *

Browse Files

Cancel of
医生账单 doctor's account

Browse Files

Cancel of
医院账单 hospital account

Browse Files

Cancel of
投保人已付款证明 proof of co-payment *

Browse Files

Cancel of
索赔返款银行账户

Banking Details for Refunds
为确保您收到此笔款项，请确认您返款银行账户。必须是主投保人银行账户。

To ensure you receive the refund, please confirm your banking details for refunds. It must be in the name of the Principal Insured.
银行账号持有人 Name of Account Holder *
银行 Bank Name *
请输入银行名称 Please insert name of bank *
Account Number *
账户类别 Account Type *

Cheque 支票账户 Savings 储蓄账户 Transmission
主投保人签字（必须跟当初申请表签字一致）Signature of policy holder *

Clear
签字日期 Date signed *

Year Month Day Date Picker Icon
Declaration
I,the undersigned ,hereby declare :

1. That to the best of my knowldege and beleif the information provided in connection with this application whether in my own handwriting or not,is true and I ahve not withheld any material facts which are known to me. (A material fact is likely to influence the assessment of this application by Sirago Underwriting Managers(Pty)Ltd. If you are in any doubt as to whether a fact is material or not ,you should disclose it)

2. That I understand that any relevant material fact ommited in this proposal form may lead to Sirago Underwriting Managers (Pty)Ltd not meeting claims,should the ommited fact have been of such importance that the risk may not have been accepted in the first instance,in terms of the policy. This may lead to the cancellation of this policy or rejection of claims without refund or premiums.

3. That I understand that this is an accident and Healthy policy with stated benefits in terms of theShort-term Insurance Act 53 of 1998 and not a Medical Schemes product

4. The sharing of claims information and underwriting information by Insurers is essential to enable the insurer is essenntials to enable the insurance industry to underwrite policies,assess risks fairly,reduce the incidence of fraudelent claims and protect the public in terms of limiting excessive premium increases.You hereby waive any right to privacy of any insurance information provided by you or on your behalf ,in respect of any insurance policy or claims you lodge.You also consent to this informaion being disclosed to any other insurance company and/or verified against other legitimate source or a database.

5. I specifically consent to Sirago Underwriting Managers(Pty)Ltd contacting my current Medical Scheme and or medical practioner to verify any medical details as provided in my application form.I further consent to such information being disclosed to Sirago Underwriting Managers (Pty)Ltd for purpose of verifying the disclosure as provided on my application form
Declaration by Applicant
I,the undersigned ,hereby declare that to the best of my knowledge and beleif the information provided in connection with this application whether in my own hand writing or not,is true and I have not withheld any material fact which are known to me.(A material fac is likely to influence the assessment of this application by Sirago Underwriting(Pty)Ltd. If you are in any doubt as to whether a fact is material or not ,you should disclose it
Should be Empty:

Sirago 申请索赔 Claim Form

主投保人资料

上传文件

索赔返款银行账户

Declaration

Declaration by Applicant