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: