Health insurance claim

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Insurance claims can be submitted only by the insured person who has received medical, dental, optical, sports services or purchased medicines
Person to be insured*
Personal code*
-

Insured person’s actual address*
Postal code*
LV-
Phone number*
E-mail address*
I agree that the Insurer shall send information on the insurance claim case to the specified e-mail address

Disbursement of indemnity (Attention! Due to the PNB bank operation suspension we kindly ask to choose other bank accounts. The insurance indemnity will not be transferred to the PNB Bank account.)*

Please indemnify costs for services provided due to the insurance event in accordance with the health insurance agreement.*
Beneficiary – insured person
    Transfer to account. IBAN account No.
    b) In cash in customer service center
Beneficiary – supporter of the insured person
    Name and surname of the insured person’s supporter
    Personal code
    -
    Transfer to account. IBAN account No.
    b) In cash in customer service center

Description of the documents attached*

Treatment services received in relation to the result of action/inaction of a third party (natural or legal person) or as a result of injuries from a traffic accident*

Yes     No
Information on the person having caused the accident
Accident date*
Identity number/Registration number
Police report No.
State reg. No.
I hereby undertake to provide all the information available to me on this case, and to cooperate in order to obtain additional information necessary for examination of this claim.
If the Insurer will recover full amount of the paid insurance indemnity during the insurance period (by recourse), then the limits paid under the insurance program would be increased by this amount, less the insurer’s administrative costs incurred in connection with the recourse procedure in amount of 25% of the recovered amount in the case of injuries resulting from a road traffic accident (RTA)
I hereby certify that in this insurance claim completed and submitted by me*
1. All the information provided is true. I am aware of the fact that in the case of provision of incorrect or misleading information the Insurer has the right to refuse to pay insurance indemnity to me and terminate the insurance contract.
2. The Insurer, prior to payment of indemnity, shall have the right to review and request any additional medical documentation required for calculation of insurance indemnity. I certify that in accordance with the Personal Data Protection Law and other laws and regulations of the Republic of Latvia I authorize Seesam Insurance AS Latvian Branch, as a system administrator and personal data operator, to process my data, including sensitive personal data and personal (classification) codes, to ensure performance of the insurance contract, as well as authorize Seesam Insurance AS Latvian Branch to receive from other entities or persons my data, including sensitive personal data and personal (classification) codes, to ensure performance of the insurance contract.
3. I undertake not to request compensation from other institutions for the received insurance indemnity, and I undertake to keep the original documents supporting the payments made to me for three (3) years from the date of receipt of the service and upon request promptly present the said originals to the Insurer, if in insurance policy, terms and conditions are not determinate otherwise.

I agree that contact information will be stored on your computer.
 
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