Claims Students Signature

Claim Submission

Any person who knowingly files a statement of claim containing any misrepresentation or any false,
incomplete or misleading information may be guilty of a criminal act punishable under law and may be subject to civil penalties.

The above answers are true and correct to the best of my knowledge.
I authorize any physician, medical institution, pharmacy, insurance company, employer, labor union, or association to release information to dhig Gmbh, KOOPERATIVA poisťovňa, a. s. Vienna Insurance Group, to Europ Assistance CIS and to Global Assist, as required to properly pay all benefits, if any due to me, my spouse, or any other dependents.
A photocopy of this authorization shall be considered effective and valid as the original.

Consent:

Personal Information:

Insurance Information:

Details of the claim:

Hospital & Physician information:

Bills / Receipts:

Reimbursment:

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Your legal name

Your email address

Please Confirm full name and signature.

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I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

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Timestamp

Audit

11/02/2021 11:26 CEST

Claims Students Signature Uploaded by daily health insurance group dhig - contact@dhig.net IP 10.80.0.109

11/02/2021 11:29 CEST

dail health claims - claims@dhig.net added by daily health insurance group - admin@dhig.net as a CC'd Recipient Ip: 10.70.0.172

30/08/2021 12:32 CEST

daily health claims - claims@dhig.net added by daily health insurance group dhig - contact@dhig.net as a CC'd Recipient Ip: 10.80.0.109