Services
   

Download Forms

Please find PDF versions of our forms below. Word versions of our Claim and Treatment Guarantee Forms are also available below, which allow you to edit and save the forms on your computer (for use again at a later date). These forms are especially useful where you have on-going treatment for which you need to claim.

Once completed, you simply print, add the necessary signatures and return to us for processing. If you have any queries, please contact our Helpline.

>Application Forms   >Dental Questionnaire
>Claim Form   >Treatment Guarantee Form

 
   

Application Form

If you are an individual applicant and wish to make payment (via Visa or Mastercard) please complete the Online Application Form. However, if you wish to make payment via cheque or bank transfer or if you are a member of an Allianz Worldwide Care underwritten Group scheme, please complete and return the PDF form below.
   
 
>Application Form
   
If there is not sufficient space on the form for all your dependants, please use a second form. Also, please ensure that you and all your dependants sign the form, then mail it to Allianz Worldwide Care at the address on the form.
 
   

Dental Questionnaire

If you are seeking dental cover and you have answered 'Yes' to any section of the dental declaration in the Individual Application Form or the Group Employee Form - with Medical Underwriting, then you would need to complete the following Dental Questionnaire.

 
>Dental Questionnaire

 
   

Claim Form

Please complete this form to obtain reimbursement of eligible medical expenses from Allianz Worldwide Care. The Claim Form can be used for in-patient, out-patient and dental claims. Please use one Claim Form per person and per condition.

 
>Claim Form (Editable Word Version)
 
>Claim Form (PDF Version)

Top tips

Before you make the claim, please ensure that your plan covers the treatment you are seeking

  1. Ensure that the doctor provides all relevant medical information, including diagnosis, in the specified section and then dates, signs and stamps the Claim Form. However, if your invoices contain details of the diagnosis, as well as the nature of the treatment, there is no need for your treating doctor to repeat this information on the form.
  2. Attach all original supporting documentation, invoices and receipts to the Claim Form.
  3. Specify on the Claim Form the currency in which you wish to be paid, otherwise the benefit due to you will be paid in the currency of the invoice.
  4. Please ensure that the payment details section is completed correctly and in full. We require the following to be completed in order for us to issue payment to a bank account:
    • Name of account holder - the exact name which appears on the bank statement of the account
    • Account number / IBAN
    • Sort / branch code
    • Swift code
    • Name of bank
    • Address of bank
  5. If you are in any doubt, please contact your bank and they can provide you with the details. If all details are not supplied the payment may be rejected by the receiving bank.
  6. All claims should be submitted to us within 6 months after the end of the Insurance Year. Beyond this time we are not obliged to settle this claim.
 
   

Treatment Guarantee Form

Treatment Guarantee is a process whereby Allianz Worldwide Care guarantees cover for certain treatments and costs. The process requires that a Treatment Guarantee Form is completed by your physician and faxed to our claims department for approval prior to treatment. We will respond within 24 hours of receipt of a fully completed form.

Treatment guarantee is required for the following;

  • In-patient benefits as listed in your Core Plan
  • MRI (Magnetic Resonance Imaging) and PET (Positron Emission Tomography) scans
  • Nursing at home
  • Routine maternity including complications of pregnancy and childbirth (in-patient treatment only)
  • Oncology (in-patient and day-care treatment only)
  • Rehabilitation treatment
  • Medical evacuation (or repatriation where covered)
  • Expenses for one person accompanying an evacuated/repatriated person
  • Repatriation of mortal remains

By following the treatment guarantee process, we can ensure that your treatment will be free from financial worries, allowing you to concentrate on getting better.

 
>Treatment Guarantee Form (Editable Word Version)
 
>Treatment Guarantee Form (PDF Version)

             

Forms

Quick links to forms downloadable from this page.

>Application Form
>Dental Questionnaire
>Claim Form
>Treatment Guarantee
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