International Insurance Form

Instructions

Complete and sign the medical claim form, indicating whether the doctor/Hospital has been paid.

Attach original itemized bills for all amounts being claimed. No reimbursement will be considered for medical expenses not accompanied by original bills. When reimbursement of an expense is approved, it will be made to the provider of the service unless the bill is noted as having been paid by you. Payment will be in US dollars unless otherwise requested.

 If payment is to be made to the provider of the service, the provider's name, address, telephone number and taxpayer identification number (if the provider is in the U.S) must be included on the bill. If payment is to you, it will be mailed to your U.S. address unless otherwise requested.

Submit form and attachments to Cultural Insurance Services International, River Plaza, 9 West Broad Street, Stamford, CT 06902~3788. For claim submission questions call (800) 303-8120

Name Date of birth ~- U.S. address

E-mail address

Phone ( ) Departure date from us / /

Date/place/time/description of injury/Sickness/Accident Attach itemized bills for all amounts liein!1 claimed

Have these doctor/Hospital bills been paid by you? D yes D no

I authorize payment to provider of service for medical services claimed D yes D no

I hereby authorize any insurance company, Hospital or Physician to release all information which may have a bearing on benefits

payable under this plan I certify the information furnished by me in support of this claim is true and correct

Signature Date / /