MEDICAL EXPENSE Claim Checklist

• Claim Form – N.I. 114. This form is completed when the insured has suffered a personal injury due to a job related incident and pays his own medical expenses.
• ALL fields must be completed. ALL changes MUST be initialed.
• Identification Card of Insured.
• Original & Copy of the Birth Certificate / Affidavit / Deed Poll where there is a change to the insured's name.
• ALL original or certified copies of receipts to support the expense being claimed MUST be submitted. The receipts MUST relate to the injury claimed. The insured's name and date of the accident MUST be stated on the receipt.
• If the method of payment is Financial, the bank statement reflecting the name of the bank, the account number and the branch should be submitted. If the method of payment is Postal a utility bill, no older than three (3) months should be submitted.
• If the claim is being submitted by a third party, the Identification Card of the third party MUST be presented.
• The claim MUST be submitted within three (3) months from the date the expense was incurred, if not a letter MUST be written with an explanation for the late submission.