ACCIDENT AND ILLNESS CLAIM FORM

HOW TO SUBMIT CLAIM FORM

Please e-mail Scan copies of the completed claim form along with all supporting documents / reports/ bills/ invoices to mayfair.claims@ihmsworldwide.com

PLEASE READ THIS CAREFULY

1.

Please send the claim form only by the official company email ID.

2.

This form is to be used when filing a claim for reimbursement of Medical Expenses and MUST be completed by the Insured in full.

3.

Fully itemized bills including Claimants Name, Nature of Illness/Injury, and diagnosis must be included with this claim form.

4.

This form must be signed and dated in all applicable sections.

5.

This form and all attached bills must be submitted as Email Scan copies.(preferably in PDF)

6.

Complete Bank details needed (Incorrect details may lead to short transfer, bank transaction charges may be applicable.)

INCOMPLETE CLAIM FORM MAY DELAY REIMBURSEMENT PROCESS

HELPFUL HINTS
1. When you are submitting expenses for more than one family member, please use a separate claim form for each person and each medical condition.
2. It is suggested that you make copies for your own use before you submit the original bills if so requested for the Claims Team.
3. Prescription Drugs-Bills must show the patients name, date of service, prescription number amount paid, name, strength & quantity of drug, the name
and address of the pharmacy.
4. If the provider needs to be paid please mention providers bank details

******************************************************************************************************************************
Name of Client Company: _________________________ Name of Employee: ____________________________________
Employee Number: ______________________________ Mayfair ID Number: ____________________________________

Email ID: _________________________________________ Date of Birth ___/___/____ Sex: Male

Female

Current Residence Address: ____________________________________________________________________________

Daytime Phone Number: __________________________Mobile Phone Number: ___________________________________
Permanent Address (In Home Country):
______________________________________________________________________________________________________

SETTLEMENT DETAILS:

Bank details (For Wire Transfers):

A) Beneficiary Name: _________________________________________________
B) Bank Name: ______________________________________________________
C) Bank Address: ____________________________________________________
___________________________________________________________________
___________________________________________________________________
D) IBAN number (Europe/Bahrain/UAE) ___________________________________
BSB Code (Australia) ________________________________________________
Transit/Sort Code (Canada, South Africa) ________________________________
IFSC Code (India) __________________________________
Clabe number (Mexico) _____________________________
Bank Routing code/sort code/branch code (Indonesia/Malaysia/ Singapore) ___
___________________________________________________________________
E) Account number: ____________________________________
F) Swift code (mandatory) ________________________________
G) Your account currency ________________________________
Address details (if requesting cheque payment only):
A) Beneficiary Name: _________________________________________________
B) Address with Post code: ____________________________________________
__________________________________________________________________
___________________________________________________________________
C) Your account currency __________________________________
CHEQUES ARE SENT OUT BY POST AND POSTAL DELAYS ARE OUT OF OUR CONTROL

Note: If the bank details are other than the primary member, please send a mail from your official email ID authorising the alternative bank details.
This page of the claim form can be saved and used for all claims submitted as long as the above details remain the same, only the second page can be
altered accordingly.
ORIGINALS ORIGNALS WOULD BE REQUESTED ON A CASE TO CASE BASIS
Postal Address: INTERNATIONAL HEALTHCARE MANAGEMENT SERVICES PVT LTD.
Mayfair Claims Department, 6th Floor, Tower 2, 'E City', Phase 1, Electronic City, Survey no. 94/2, Bangalore - 560 100 INDIA.
TOLL FREE: + 800 MAYFAIR0 (+ 800 6293 2470) CALL COLLECT TEL NO. : + 1 317 818 2800 Direct No: - +91 8030147200 (Mon to Fri 8.00 am to 7.00 pm IST)

Name of Patient: ____________________________________Mayfair ID Patient: __________________________________

Date of Birth ___/___/____ Sex: Male

Female

Relationship Self

Spouse

Son

Daughter

If Accident, provide details, i.e., how when and where accident occurred
_______________________________________________________________________________________________________
If Illness, advise when and where symptoms first occurred and nature of illness___________________________________
Exact diagnosis: _______________________________________________________________________________________
If Maternity Related (Date of confirmation of pregnancy/ Estimated date of delivery/ Any complications foreseen)
_______________________________________________________________________________________________________
Consulting Physicians Name: ___________________________________________________________________________
Address: _________________________________________________________Phone Number: _________________
Has Mayfair assistance / Sevencorners been contacted with regards to this illness. Yes
Have you ever been treated for this Illness before? Yes
Have you been completely cured of the above diagnosis Yes

No

No

Any GOP issued for the same Yes

No

If Yes, when? _______________________________________

No

Please advise names of any prescription medications you are presently taking: _________________________________________
Indicate other Health Insurance coverage, include name, address, policy number and certificate number of Insurer: __________
_____________________________________________________________________________________________________________
Any Other Information that you would like to provide: _______________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________

Details of Expenses Claimed

Dates of Treatment

Service provided

Currency

Amount Paid

RECEIPTS No.

The furnishing of this form, or its acceptance by the Company, must not be construed as an admission of any liability on the Company, nor a waiver of any of the conditions of the
insurance contract. Any person who knowingly and/or with intent to injure, defraud, or deceive an insurance company or other person files a statement of claim containing false,
incomplete or misleading information, may be guilty of insurance fraud and subject to criminal and substantial civil penalties.

I, the undersigned authorize any hospital or other medical-care institution, physician or other medical professional, pharmacy, insurance support organization, governmental agency, group
policyholder, insurance company, association, employer or benefit plan administrator furnish to the Claims Administrator named above or its representatives, any and all information with respect
to any injury or illness suffered by, the medical history of, or any consultation, prescription or treatment provided to, the pe rson whose death, injury, illness or loss is the basis of claim and copies
of all of that persons hospital or medical records, including information relating to mental illness and use of drugs and alcohol, to determine eligibility for benefit payments under the Policy
Number identified above. I authorize the group policyholder, employer or benefit plan administrators to provide the Claims Administrator named above with financial and employment-related
information. I understand that this authorization is valid for the term of coverage of the Policy identified above and that a copy of this authorization shall be considered as valid as the original.

I understand that I, or my authorized representative, may request a copy of this authorization.

In addition, I hereby certify that the above information is true and correct to the best of my knowledge and belief.
_____________________________________________
Signature of Claimant or Parent, If Claimant is a Minor

______________________
Date