AXA Reimbursement Claim Form
AXA Reimbursement Claim Form
AXA Reimbursement Claim Form
Date of admission:
dd/mm/yyyy For reimbursement only For hospitalization only
Date of treatment:
Date of discharge:
Email address:
B. Medical section
Symptoms presented Date the patient first became Date on which the patient
aware of any signs or first presented to any doctor
symptoms for this condition: for this condition:
dd/mm/yyyy dd/mm/yyyy
Medical condition/diagnosis
C. Treatment advised
Drugs Dose Frequency Duration
If you have answered 'yes' to either of these questions, please give the name of the Insurance company involved.
Payment will be made in the currency defined in your plan unless we agreed otherwise in writing.
In which currency was the treatment originally billed?
Mobile No:
H. If you are claiming for treatment received outside your area of cover, please answer the
following questions:
(a) Country where the treatment took place
(c) Date of departure and return to own area of cover: From : ___ / ___ /____ To : ___/___/____
Are you claiming cash benefit for in-patient treatment? Please tick Yes No
If you have any questions regarding this form or any other aspects of the cover, please contact AXA on UAE +971 (4) 429 4000, Qatar +974 412 8733,
PB36309a/01.10
Bahrain +973 (17) 582 612, KSA +966 (1) 478 0282 quoting your group and membership numbers.
Claims must be submitted along with supporting documents within 90 days from date of service. Send this claim form together with supporting material to Medical
Department, AXA Insurance, PO BOX 32505, Dubai, UAE or AXA Insurance, P.O. Box 45, Kingdom of Bahrain or
AXA Insurance PO BOX 21044, 11475 Riyadh, Kingdom of Saudi Arabia or AXA Insurance, PO Box 15319, Doha, State of Qatar