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 POLICYHOLDER
Policyholder First Name: *		Policyholder Last Name: *
Title: *
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:

Details of policyholder’s relevant Previous Medical History

TRAVEL INSURANCE DETAILS
Name of insurance / scheme: *		Policy No:
Policy valid from / to:		Policy issue date:
Where purchased:		Policy Lead name
Address of issuer:		Issuing agent’s Tel No:

OTHER INSURANCE
Private Health Insurance:	YesNo	Other travel insurance:	YesNo
Details

POLICYHOLDER’S TRAVEL ARRANGEMENTS
Outbound Flight Date: *		Outbound Flight No: *
Return Flight Date:		Return Flight No:
Airline
UK Airport		Overseas Airport:
If applicable details of other means of transport (e.g. via train, car, coach etc):
Tour Operator:		Tour Operator Booking Reference:
Contact Details for local Tour Operator Rep:		Names and relationship of travel companions: