Get Van Breda Claim Form - Un.org 2011-2025

Filling out the Van Breda Claim Form for reimbursement of medical expenses is a straightforward process designed to be user-friendly. This guide will walk you step-by-step through each section of the form, ensuring you provide all necessary information correctly.

Follow the steps to effectively complete your claim form.

1. Press the ‘Get Form’ button to access the claim form and open it in your preferred editor.
2. In the first section, enter the subscriber's name, making sure to list the last name followed by the first name. Next, specify the administering office or organization along with the duty station, including the city and country.
3. Provide your correspondence address and email address. This is essential for receiving updates regarding your claim.
4. Fill in the name of the patient and their date of birth in the specified format (day/month/year). Be sure to select the patient's sex.
5. Indicate the relationship of the patient to the subscriber by selecting the appropriate option, whether it is 'Self', 'Spouse', or 'Unmarried dependent child'.
6. Answer whether the patient is covered under after-service health insurance arrangements. If yes, provide the place of residence.
7. Enter the total amount claimed in the specified currency and note the number of attachments being submitted with your claim.
8. If applicable, state whether the claim is reimbursable by another insurance and if a third party is involved in any accident related to the claim.
9. Indicate if the illness or injury was related to employment and provide all details as requested.
10. Choose your preferred mode of reimbursement: by electronic transfer or cheque. Ensure you provide all necessary banking details if you choose electronic transfer.
11. Sign and date the claim to certify that the statements provided are correct and that you were enrolled in the UN Medical, Hospital, and Dental Scheme during the relevant period.
12. Make sure that the Resident Representative or Administrative Officer has signed the claim, except for subscribers of after-service health insurance.
13. Submit the original claim form along with all required documents to Vanbreda International at the provided address.
14. After completing the form, you can save changes, download the form, print it out, or share it as necessary.

Complete your claim form online and ensure a smooth reimbursement process.