Thank you for submitting your claim online. Please note that the declaration at the end of this online form must be read and accepted by each policy owner and the claimant (or their parent/guardian if under 16) before it's submitted. The policy owner(s) will be notified about this claim.

Attachment hints

Single file size can not exceed 3MB. Total file size for all attachments can not exceed 20MB. Only file of type: PDF, DOC/DOCX, JPG/JPEG or PNG is allowed as attachment.

Please only attach JPEG, jpg or png image files from your photo gallery. If you have a PDF or any other document, please take a photo and upload. Thank you.

Detail

Please complete the following to ensure we have all the necessary information to process your claim as quickly as possible.

Please select one (or more) of the boxes to explain what you are applying for

Prior approval (application for a future surgery or procedure - please also attach estimate of costs) Payment for a claim already prior approved Payment for a new claim not prior approved

Please select claim type

Is your treatment within the next 5 days?

Yes No Please select an answer

Document upload

Please attach your GP/dentist referral or medical certificate that confirms the date you first consulted with any Medical Practitioner for this condition.

Please only attach JPEG, jpg or png image files from your photo gallery. If you have a PDF or any other document, please take a photo and upload. Thank you.

Please note, we require for you to attach supporting medical information in the form of a GP referral, medical certificate or specialist's report before proceeding any further with the claims application.

Referral letter or medical certificate, and /or
Specialist report and estimate of costs
Files Uploaded

Before submitting your claim we require supporting medical information to be attached. Alternatively please download the following medical certificate form to be completed by a Registered Medical Pracititioner.

Medical health certification form

Download Form

Refund for claims

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.

Provider

Amount

Provider

Amount

Pay to provider

Please input Provider and Amount

Please only attach JPEG, jpg or png image files from your photo gallery. If you have a PDF or any other document, please take a photo and upload. Thank you.

Invoice or receipts

Please attach evidence of invoices or receipts
Files Uploaded
Please attach Evidence of Invoices or Receipts

Account details

(Please note: Reimbursement can only be made to a bank account, not a credit card). If we haven't paid into this account before please provide evidence of bank details such as a printed bank statement.

Name of account Please input Name of Account

Bank

Branch number

Account number

Suffix

Please input Bank Account Number

Please only attach JPEG, jpg or png image files from your photo gallery. If you have a PDF or any other document, please take a photo and upload. Thank you.

Bank account details

Please provide bank account details for reimbursement.
Files Uploaded

Policy owner details

Policy number Please input Policy Number

Product Please select an option

Title Mr Ms Miss Mrs

Surname Please input Surname

First name Please input First Name

Street Please input Street

Suburb Please input Suburb

City Please input City

Postcode

Best contact telephone number Please input Best contact telephone number

Email address Please input a valid Email Address

Date of birth Please input Date of Birth

Who is this claim for?

Policy owner (go straight to Next) Other member insured on the policy (please complete below when selected)

Title Mr Ms Miss Mrs

Surname Please input Surname

First name Please input First name

Best contact telephone number Please input Best contact telephone number

Email address Please input a valid Email address

Date of birth Please input Date of Birth

Claim details

Have you claimed for this condition before? Yes No Please select an answer

Claim number (If known)

Symptoms started Please input Symptons Started Please input a valid date in DD/MM/YYYY Future date is not allowed

Sought medical advice Please input Sought Medical Advice Please input a valid date in DD/MM/YYYY Future date is not allowed

Treatment recommended Please input Treatment recommended

Name of provider / facility

Date of admission Please input Date of Admission Please input a valid date DD/MM/YYYY

Date of discharge Please input Date of discharge Please input a valid date DD/MM/YYYY

Do you have a health policy with another provider you could claim on for this condition? Yes No Please select an answer

Is this condition ACC related? Yes No Please select an answer

Please only attach JPEG, jpg or png image files from your photo gallery. If you have a PDF or any other document, please take a photo and upload. Thank you.

ACC decision letter
Files Uploaded

Please attach ACC Decision Letter

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 AIA New Zealand ("AIA") and/or any of its related entities, their advisers, their agents and reinsurers. This claim related information collected will be held at AIA's head office, 74 Taharoto Road, Takapuna and by AIA's data storage providers, including cloud-based data storage providers (whether in New Zealand or elsewhere). Both AIA and its cloud based data storage provider will take reasonable steps to keep such information secure.

AIA 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 AIA 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.

Surname

First name

I acknowledge this Declaration and consent Please accept this Declaration and Consent

Did you purchase your insurance through ASB Bank Limited (ASB)?

Yes No Please select an answer

Claimant Declaration

As part of a health insurance claim with AIA, I, the Claimant, consent and give authority to AIA 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 AIA, 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

Claimant surname Please input Parent/Guardian surname

Claimant first name Please input Parent/Guardian First name

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

I acknowledge this Declaration and consent. Please Accept this Declaration and Consent

I consent to AIA obtaining my medical records from my doctor and other medical providers noted above. Please accept this Declaration and Consent

Security check

Please enter the text shown below

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Thank you,
we have received your claim.

You don't need to do anything. We will be in touch directly with the claimant within 5-7 working days.

A notification has been sent to the claimant and /or policy owner for their records.

Sorry,
we were unable to complete your request.

Please try again later. If the problem persists please email your claim to healthclaims@sovereign.co.nz

Attachment hints

Detail

Document upload

Referral letter or medical certificate, and /or
Specialist report and estimate of costs

Files Uploaded

Medical health certification form

Refund for claims

Invoice or receipts

Files Uploaded

Account details

Bank account details

Files Uploaded

Policy owner details

Who is this claim for?

Claim details

ACC decision letter

Files Uploaded

Declaration and consent

Policy owner(s)

Claimant Declaration

Security check

Thank you,
we have received your claim.

Sorry,
we were unable to complete your request.

Need help with your claim?

Call us on

PH: 0800 500 108

PH: +64 9 487 9963

AIA.CO.NZ

Attachment hints

Detail

Document upload

Referral letter or medical certificate, and /or Specialist report and estimate of costs

Files Uploaded

Medical health certification form

Refund for claims

Invoice or receipts

Files Uploaded

Account details

Bank account details

Files Uploaded

Policy owner details

Who is this claim for?

Claim details

ACC decision letter

Files Uploaded

Declaration and consent

Policy owner(s)

Claimant Declaration

Security check

Thank you, we have received your claim.

Sorry, we were unable to complete your request.

Need help with your claim?

Call us on

PH: 0800 500 108

PH: +64 9 487 9963

Referral letter or medical certificate, and /or
Specialist report and estimate of costs

Thank you,
we have received your claim.

Sorry,
we were unable to complete your request.