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Claim Submission


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:









 

Leave this empty:

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Signature Certificate
Document name: Claim Submission
lock iconUnique Document ID: b0290bddcbbe129345170188d4b6e55f70045cef
Timestamp Audit
16/07/2020 14:10 CETClaim Submission Uploaded by daily health insurance group dhig - contact@dhig.net IP 2001:850:4706:850::1362
16/07/2020 14:23 CETClaims Department - claims@dhig.net added by daily health insurance group - admin@dhig.net as a CC'd Recipient Ip: 10.70.0.52
16/07/2020 18:16 CETClaims Department - claims@dhig.net added by daily health insurance group - admin@dhig.net as a CC'd Recipient Ip: 2a02:1b8:11:200::e820
23/07/2020 13:03 CETClaims Department - claims@dhig.net added by daily health insurance group - admin@dhig.net as a CC'd Recipient Ip: 10.70.0.52
23/07/2020 13:05 CETClaims Department - claims@dhig.net added by daily health insurance group - admin@dhig.net as a CC'd Recipient Ip: 10.70.0.52
23/07/2020 13:14 CETClaims Department - claims@dhig.net added by daily health insurance group - admin@dhig.net as a CC'd Recipient Ip: 10.70.0.52
23/07/2020 13:52 CETClaims Department - claims@dhig.net added by daily health insurance group - admin@dhig.net as a CC'd Recipient Ip: 10.70.0.52
02/09/2020 11:02 CETClaims Department - claims@dhig.net added by daily health insurance group - admin@dhig.net as a CC'd Recipient Ip: 10.70.0.52
12/05/2021 14:47 CETClaims Department - claims@dhig.net added by - as a CC'd Recipient Ip: 2a02:1b8:11:222::e820
18/05/2021 10:52 CETClaims Department - claims@dhig.net added by - as a CC'd Recipient Ip: 10.70.0.172
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This audit trail report provides a detailed record of the online activity and events recorded for this document.
https://sign.dhig.net/
Audit Trail Serial# 5e396dd38602ed874d1b7c9e31c6816e