FirstAssist - Assitance Services / Claims Notifications

16th July 2010

FIRSTASSIST DAY ONE ABSENCE MANAGEMENT SAVES CLIENT £375 PER EMPLOYEE PER YEAR

22nd June 2010

REVIEW ENSURES FIRSTASSIST'S COMPLIANCE WITH REHAB COUNCIL STANDARDS

3rd June 2010

LORICA CONSULTING LAUNCHES FIRSTASSIST ABSENCE SERVICE

Please provide as much information as possible as this will enable FirstAssist to help you

NAME/CONTACT DETAILS OF SENDER
Full Name *		Relationship to policyholder: *
Mobile Telephone		Contact / Telephone No: *
E-mail:

NAME/CONTACT DETAILS OF BUSINESS TRAVELLER
First Name business traveller: *		Last Name of business traveller: *
Title: *
Name of Employer: *		Contact details for line manager /HR etc:
Current Location:*
Town:
Home Address:		Date of Birth
		Mobile Tel:
		Home Tel:
		Overseas Tel:*
		Email:

NATURE OF PROBLEM /ASSISTANCE REQUIRED
Please provide brief details e.g. whether it is Medical / Travel assistance and what help you require from FirstAssist:


MEDICAL DETAILS
Nature of medical problem:*		Inpatient or Outpatient:
Time of admission / treatment:		Name of Hospital/treating facility:*
Address (including country in which it is located): *		Name of treating doctor and or department:
		Tel no:
		Fax No:
		E-mail:


TRAVEL INSURANCE DETAILS
Name of Business Travel insurance Policy:		Policy No:
Who administers the company Business Travel Insurance? Name of person within HR / Risk Management etc

POLICYHOLDER’S TRAVEL ARRANGEMENTS
Outbound Flight Details: *		Return Flight Details: *
Brief Details of intinerary:
If applicable details of other means of transport (e.g. via train, car, coach etc):
Names and relationship of travel companions: