Health insurance claim form

When applying for treatment or surgery, please also attach the estimated cost and a copy of the report from your specialist.

Please provide a copy of accounts or invoices (and receipt, if paid).
Payment will be made directly to the bank account you provide below, unless you elect to have payment paid directly to the provider by ticking the right-hand column of this section.

Declaration and consent

This claim form collects claim related information about you, the Policy Owner, and any Life Assured for whom you are claiming under your Policy for the purpose of assessing the health insurance claim(s) under your policy.

The intended recipient of this claim related information is Sovereign Assurance Company Limited ('Sovereign') and/or any of its related companies, their officers, their advisers, their agents and reinsurers. This claim related information collected will be held at Sovereign's head office, 74 Taharoto Road, Takapuna and by Sovereign's data storage providers, including cloud-based data storage providers (whether in New Zealand or elsewhere). Both Sovereign and its cloud based data storage provider will take reasonable steps to keep such information secure.

Sovereign may be required to disclose this claim related information if disclosure is required by law, including laws of other jurisdictions, for example to government and regulatory authorities. Failure to provide the requested claim related information or provision of incorrect claim related information may result in this claim being declined or unable to be assessed. You and any Life Assured have the right to request access to, and correction of, your respective claim related information at any time.

Policy owner(s)

I, the Policy Owner, hereby claim the benefit amounts payable on the basis of the statements and information provided by the Life Assured in this claim form which I believe to be accurate and complete in every respect. I understand payments approved by Sovereign will be made to the medical provider, or in the case of reimbursement payments will be made to the owner of the bank account provided with this claim form.

Claimant Declaration

As part of a health insurance claim with Sovereign, I, the Claimant, consent and give authority to Sovereign and any of its related companies and agents to seek from, and for all and any of the following, their officers and employees, to disclose to Sovereign, their advisers, reinsurers and to any legal tribunal before which any question concerning the insurance may arise, any medical or other claim related information affecting such insurance which they may hold in respect of me:

• Registered medical practitioners and specialists
• Accident Compensation Corporation
• Insurers (whether public or private)
• Government departments, agencies, organisations and enterprises
• Hospitals (whether public or private)
• Counsellors, psychologists and therapists
• Dentists

(For claimant under 16 years of age, name of parent or guardian must be entered above.)