Marsh PNG Medicare

CLAIM FORM
1.

EMPLOYEE DETAILS

Payroll Number:

Policy Number:

Surname:

First Name:

Employers
Address:

Date of Birth:

Work Phone No.:

(675)

Work Phone:

Your Mobile No.:

Your Gender:
2.

(675)

Contact Email:

Male

Female

Date Joined:

YOUR BANK ACCOUNT DETAILS

Your Bank
Account Number:

Your a/c
details:

Type of Account:

Branch at:

Avoid Delayed Refund - Ensure your Bank Details are correct and accurate advise Marsh of changes immediately
as incorrect or ceased account detail will disable Kundu pay system from completing a batched remittance advice).
1.

Are you covered for these expenses under any other Medical Insurance Plan, Personal
Accident Insurance or any other insurance policy or plan in PNG?

Yes

No

Yes

No

Yes

No

If Yes, please provide details

2.

Are any of the expenses you are claiming arise from a sickness/injury that occurred as a
result of your employment?
If Yes, please provide details

3.

Has the Insured person who is making this claim ever suffered from the same
sickness/injury?
If Yes, please provide details

4.

To be completed for FUNERAL BENEFIT Expenses Only

Date of Death:
Name of Deceased insured member:
Relationship to member:

5.

To be completed for LIFE BENEFIT Only

Date of Death:
Name of Deceased insured member:
Relationship to member:

6.

To be completed for PERSONAL ACCIDENT Benefit Only

Date of Death:
Name of Deceased insured member:
Relationship to member:

2.

PLEASE ATTACH THE FOLLOWING ORIGINAL DOCUMENTS:

Details of any refund from any other claim you may have made in respect of this
sickness/injury; From: e.g. Office of Workers Compensation, MVIL, or Personal
Accident/Sickness Claimed against your spouses insurance policy with another insurer.

Doc
attached

Doc
attached

Yes

No

a.

Medical Certificates

Yes

No

b.

Doctors Prescriptions

Yes

No

c.

Receipts, Invoices or Accounts, Discharge Summary or Medical Reports for Medical

Consultations, Prescriptions Medications, Treatment and if hospitalisation.

Yes

No

d.

Medical Death Certificate, Post-Mortem/Coroners Report (if applicable).

Yes

No

e.

Employers letter Confirming Deceased employees details

Yes

No

ALL CLAIMS MUST BE SUBMITTED WITHIN 30 DAYS

MEDICAL AUTHORITY
I hereby authorize all hospitals, doctors, or any other person who has provided me and/or my spouse and/or my dependents
with medical treatment to supply to Marsh Limited or its representative with any information that the company may require
in relation to any injury/sickness or medical history in connection with any claim for medical expenses.
I agree that a photocopy or facsimile of this authority will be as effective and valid as this original.
Signed: _______________________________
Name of
Insured
Person

Relationship
to Member

Name of
Hospital,
Clinic,
Doctor
etc

Date of First
Consultation

Date: ______/___________/_________
GIVE REASON
Nature of Sickness / Illness
or Type of Injury
(Please provide full details)

Date of
Treatment

Amount
of Claim

I hereby submit this claim for Medical expenses incurred for the professional services to which this claim relates and do
solemnly and sincerely declare that:
1.

I have incurred the expenses

2.

That services I am claiming are not claimable under any other insurance, including Workers Compensation, Personal
Accident/Sickness and MVL, and or other Private Medical Insurance i.e. Medicare, or from my Spouse insurance
cover with his/her employers insurance cover.

3.

All the information contained in this claim form is true and correct to the best of my knowledge. Further, I have not
made any fraudulent or false statements or concealed any information relative to this claim.

4.

Find attached original supporting documentation.

Signed: _______________________________

Date:

________/___________/_________

INTERNAL ONLY
TO BE COMPLETED BY MARSH STAFF ONLY
3.

LODGEMENT DETAILS WITH MARSH LTD

Date Claim lodged with Marsh: ______/________/_______

Yes

Tick Documents In Order to Pay

If no, give details:

Batched by: __________________________

No

Check by whom: _______________________

___________________________________________________

________

Payment made by whom at: PMMI to members Account: Print Name:

Date sent to Bank:

______/________/_______Entered by Who: _____________________

Marsh updated on:

______/________/_______ Marsh update issued by whom: _____________________

4.

INCOMPLETE OR REJECT CLAIM FORM BATCH REVIEWED BY MARSH & PMMI

Date Claim checked by Marsh & PMMI: ______/________/_______

PMMI sign off by: _____________________
Approval for Payment:
If no, give details:
Payment made by who at

Yes

No

Date of Approval: ______/______/_______

___________________________________________________
PMMI to members Account: Print Name:

Date sent to Bank:

______/________/_______Entered by Who: _____________________

Marsh updated on:

______/________/_______ Marsh update issued by whom: _____________________

ADVISE MEMBER OF REASONS FOR DECLINING.