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Letter to Claim from Medical Insurance - Template Form Pro · AU-law

✓ Valid in Australia · drafted to comply with local law

Create your Letter to Claim from Medical Insurance - Template Form for use in Australia. Answer a few plain-English questions and the document fills in automatically as you go — then download it in Word and PDF, ready to sign or share. This version has been professionally rewritten to comply with local law.

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Letter to Claim from Medical Insurance - Template Form
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________
________
Telephone: ________
Email: ________

________

The Claims Department
________
ABN/ACN: ________
AFSL No.: ________
________


RE: INSURANCE CLAIM – Policy Number ________

Policyholder Name: ________
Claim Reference (if known): ________


Dear Sir or Madam,

I refer to the above policy of insurance issued by ________ (the Insurer) and write to lodge a formal claim under that policy in accordance with its terms and conditions, the Insurance Contracts Act 1984 (Cth) and the General Insurance Code of Practice.

1. Particulars of the Claim

Insured/Patient: ________

Provider: ________

Date services rendered/event occurred: ________

Description of the loss, event or treatment giving rise to the claim: ________

2. Supporting Documentation

In support of this claim, and consistent with my duty under sections 13 and 14 of the Insurance Contracts Act 1984 (Cth) to act towards the Insurer with the utmost good faith, I enclose the following:

(a) a completed and signed claim form;

(b) a statement from the provider;

(c) tax invoices, receipts and/or other evidence of the expenses incurred;

(d) ________

3. Amount Claimed

On the basis of the enclosed documentation, I claim reimbursement and/or indemnity in the amount of $________ (________).

4. Payment

I request that any amount payable be remitted in the following manner:

________

Account name: ________

BSB: ________   Account number: ________

5. Declaration and Authority

6. Processing and Complaints

Please find all relevant documentation enclosed with this letter. Should you require any further information or additional documentation in order to process this claim, please do not hesitate to contact me at your earliest convenience using the details provided above. Thank you for your prompt attention to this matter.


Yours faithfully,




________
Date: ________

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