Hospital Stay Benefit
To claim for a hospital stay, please upload a copy of your discharge letter.
Payment will be made directly into the bank account details we hold on record for you below. If the section is blank please provide details of the bank account you wish to receive payment.
I declare that I am not claiming for this claim under another health insurance product
I understand that any fraudulent claims may result in legal action being taken and immediate cancellation of my policy
I consent to ASFS processing any health and medical information contained in this form in order to pay my claim
I authorise any medical practitioner or other person(s) concerned with providing healthcare to give you any information relevant to this claim
I declare the information shown on this form and any accompanying documentation is true and complete