Hollard Gap Claim Step 1 of 11 0% FacebookThis field is for validation purposes and should be left unchanged. To claim against your Hollard gap cover benefits you need to complete this form and attach all the relevant claim documents once prompted. The supporting documentation that will required is as follows and can be uploaded online while completing this form: The relevant account from the doctor/provider The claims statement from the medical scheme showing how they have processed and paid the above account The first 2-3 pages of the hospital account showing the admission/discharge dates, ICD-10 codes, patient name, etc (if applicable) Claims are processed continuously and are paid daily. Once we have finalised your claim we will issue you with a claim remittance via e-mail. Important : The assessment of your claim can only start once we have received a fully completed claim form and all the relevant supporting documentation. Policy Holder DetailsTitle(Required)MrMrsMsMissName(Required) First Last ID or Passport Number(Required)Cellphone Number(Required)Alternative Contact NumberEmail(Required) Enter Email Confirm Email Medical Scheme(Required)Please select your Medical SchemeGemHealthNammedNAPOTELNHP(Namibia Health Plan)NMC (Namibia Medical Care)RMA(Renaissance Health)Benefit Option(Required)Membership Number(Required)Hollard Policy Number (If Available) Patient DetailsName(Required) First Last Date of Birth(Required)YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031Gender(Required) Male Female Relation to Policy HolderMain MemberSpouseChildSpecial DependentAdult Details of Medical Service ProvidersName of Doctor(Required)Telephone Number(Required)Practice Number(Required)This field is hidden when viewing the formDate of Treatment(Required) DD slash MM slash YYYY Name of Hospital (if applicable)Please provide details or description of the illness & treatment(Required)Does your claim include any shortfalls for a casualty ward(Required)NoYesNature of your shortfall(Required)InjuryIllnessOtherDate of Injury(Required)DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Where did the injury occur? Please select one of the following options:(Required)HomeSchoolWorkMotor Vehicle AccidentDuring Social SportsDuring a Professional Sporting EventOtherPlease provide a detailed description of the injuries sustained, including what the injuries are and how they were causedWere you the driver of the vehicle?(Required)YesNo Shortfall Details To accurately assess your claim please provide us with the details of each service provider/s you would like to claim for. Service Providers Provider Name Treatment Date Amount Claimed Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Document Upload Upload Hospital Account(Required) Drop files here or Select files Max. file size: 5 MB, Max. files: 2. Document UploadUpload the accounts from the various Doctors and/or Service Providers(Required) Drop files here or Select files Accepted file types: jpg, gif, png, pdf, doc, docx, jpeg, tif, Max. file size: 10 MB, Max. files: 5. The claims remittance from your medical scheme This needs to show how they have processed and paid the above doctor’s account.Upload Medical Scheme Remittance(Required) Drop files here or Select files Accepted file types: jpg, gif, png, pdf, doc, docx, jpeg, tif, Max. file size: 3 MB, Max. files: 3. Additional DocumentationUpload any additional documentation that you may deem relevant to your claim Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 5 MB, Max. files: 7. Payment Details Where applicable, we will pay your doctor directly. If you have already paid your doctor, we will refund you.Have you already paid your doctor?(Required)YesNo Please provide your bank account details below : Bank Name(Required)Bank WindhoekFirst National Bank of Namibia (FNB)Letshego Bank NamibiaNedbank NamibiaStandard Bank NamibiaTrustco Bank (TBN)Account Holder Name(Required)Account Type(Required)CurrentSavingsTransmissionAccount Number(Required)Branch Code(Required)We will contact your doctor and arrange direct payment of the account – please do not settle your doctor’s account until we have processed this claim. Declaration & Submission I, hereby provide explicit consent to Hollard(Pty) Ltd, its sub-contractors and/or its underwriters to: Use my personal information and the information supplied in this claim form to provide me with administrative and insurance services; and Negotiate with any of my medical service providers on the fees that they have charged; and Engage with any of my medical service providers on whether their fees are compliant with prevailing legislation; and Disclose information to persons and entities that it is necessary to disclose this information to in order to provide me with the aforementioned services; and Communicate with me electronically about any changes or general information relating to administrative processes or changes to my policy, benefits, premiums and/or claims processes; and Transfer my personal information outside Namibia if I have provided an email address that is hosted outside Namibia or to administer certain services, for example, cloud services; and Obtain any medical records, medical claims or personal information of myself or my dependants from my/our medical scheme and/or my/our medical service providers, including their sub-contractors who process or transfer the relevant medical records, medical claims and/or personal information; and Obtain any medical records, medical claims or personal information for myself or my dependants from any medical data bureau or credit bureau who respectively act as aggregators of medical and credit information. I further agree and confirm that: All details supplied in this form and the supporting documentation are true and correct; and I am aware that any non-disclosure or misrepresentation may result in this claim being rejected or my policy cancelled or voided from inception; and By submitting my dependents’ personal information, I hereby confirm that I am authorised to share such information; and If I am submitting this claim for a dependent under the age of 18 years (a minor), I confirm that I have the authority to act on their behalf. You also acknowledge that that you have read and agreed to the Hollard Privacy Statement and the contents thereof. Consent(Required) I hereby acknowledge and agree to the above.Signature(Required)
