TFG DENTAL CLAIM FORM

Assigned to:
TFG DENTAL PLAN AND TFG DENTAL PLAN FAMILY CLAIM FORM

Must be completed by the Account Holder. PLEASE NOTE: If you are unable to submit the claim form online, you may download the form and send the completed claim form together with your supporting documents (ID, valid statement or quote, proof of address, proof of bank account) to: Fax: 0866 737 336 email: TFG@denisinsurance.com
SECTION A: TFG ACCOUNT HOLDER'S DETAILS
TFG Store Account Number*
All benefits in respect of valid claims will be paid to the policyholder provided that the insured is in good standing.
Main Member Name*

First NameLast Name
Date of Birth

DayMonthYear
Date
ID Number*
A South African ID is a 13-digit number
Email Address*
example@example.com
Cell Number*
Enter a valid phone number starting with 0.
Postal Address*

Number, Street name / PO Box

Suburb

CityProvince

Postal Code
Province
I am submitting a claim for:*

MyselfMy PartnerMy Child
Partner Name

First NameLast Name
Child Name

First NameLast Name
SECTION B: DENTIST DETAILS

A claim may only be submitted AFTER a diagnosis by a Dentist has been completed.
Dentist Name*
Date of Visit (DD/MM/CCYY)*

DayMonthYear
Diagnosis/ Treatment Date
Practice Number*
Please request this from your dental practitioner.
SECTION C: ACCOUNT HOLDER'S BANKING DETAILS

The MAIN MEMBER'S bank account details, into which the claim payment will be made. PLEASE NOTE: the details provided in this section must match the details in the proof of bank account that you provide us; if the details do not match we will not be able to process payment. All benefits will be processed electronically.
Initials and Surname of the holder of this bank account
All benefit payments will be made payable to the main member.
Bank
Account type
Branch Name
Branch Code
Bank Account No.
Please note: we require the details of your bank account NOT your card number. We will not be able to process your claim if you enter your card number.
SECTION D: CLAIM DETAILS

If you are unsure about the claim details specified in this section, please request assistance from your treating dental practitioner to help with completing this section.
Are you claiming for an event relating to a specific tooth/ teeth?

Severely decayed or damaged tooth (DAY TO DAY BENEFIT)Impacted wisdom tooth (tooth numbers: 18, 28, 38, 48) (DAY TO DAY BENEFIT)Chipped tooth (ACCIDENT BENEFIT)Fractured tooth (ACCIDENT BENEFIT)Knocked tooth (ACCIDENT BENEFIT)Dental abscess (EMERGENCY BENEFIT)
Are you claiming for a general event (not related to a specific tooth)?

Day to day dental event (DAY TO DAY BENEFIT)Dental emergency (EMERGENCY BENEFIT)ORAL CANCERJAW FRACTURE
How many teeth were affected?
Sub-total: tooth specific
DECAYS, IMPACT, Accident
Sub-total: general event
DEVENT, Dental Emergency, ABSCESS, JAW, Cancer
Give a brief description of the accident (if claiming for an accident)
NOTE: an accident report or medical certificate indicating the nature of the external blow is required where claiming for accidental trauma benefits.
Tooth Chart Draw on Image: circle the tooth/teeth affected
Select the applicable tooth number(s) with reference to the tooth chart above (UR = Upper Right, UL = Upper Left, LL = Lower Left, LR = Lower Right)

11 UR Central incisor21 UL Central incisor31 LL Central incisor41 LR Central incisor12 UR Lateral incisor22 UL Lateral incisor32 LL Lateral incisor42 LR Lateral incisor13 UR Canine / cuspid23 UL Canine / cuspid33 LL Canine / cuspid43 LR Canine / cuspid14 UR 1st premolar / bicuspid24 UL 1st premolar / bicuspid34 LL 1st premolar / bicuspid54 LR 1st premolar / bicuspid15 UR 2nd premolar / bicuspid25 UL 2nd premolar / bicuspid35 LL 2nd premolar / bicuspid45 LR 2nd premolar / bicuspid16 UR 1st molar26 UL 1st molar36 LL 1st molar46 LR 1st molar17 UR 2nd molar27 UL 2nd molar37 LL 2nd molar47 LR 2nd molar
Tooth Chart Draw on Image: circle the primary tooth/teeth affected
Select the applicable primary tooth number(s) with reference to the tooth chart above (UR = Upper Right, UL = Upper Left, LL = Lower Left, LR = Lower Right)

51 UR Central incisor61 UL Central incisor71 LL Central incisor81 LR Central incisor52 UR Lateral incisor62 UL Lateral incisor72 LL Lateral incisor82 LR Lateral incisor53 UR Canine / cuspid63 UL Canine / cuspid73 LL Canine / cuspid83 LR Canine / cuspid54 UR 1st premolar / bicuspid64 UL 1st premolar / bicuspid74 LL 1st premolar / bicuspid84 LR 1st premolar / bicuspid55 UR 2nd premolar / bicuspid65 UL 2nd premolar / bicuspid75 LL 2nd premolar / bicuspid85 LR 2nd premolar / bicuspid
SUPPORTING DOCUMENTS

Processing of your claim cannot start until we have the completed claim form together with all the supporting documents: (1) copy of your Identity Document (2) treatment quotation or treatment invoice (3) accident report if you are claiming for an accident (4) proof of address less than 3 months old (5) Proof of bank account. YOU MAY UPLOAD MORE THAN ONE DOCUMENT AT A TIME. If you are unable to upload your files online, you may send the supporting documents to fax: 0866 737 336 or email: TFG@DENISINSURANCE.COM using your FULL NAME and ID as the subject. Claims and supporting documents may also be submitted at any TFG store.
File types supported for document upload: pdf, doc, docx, xls, xlsx, csv, zip, jpg, jpeg, png, gif (max 3MB)
Treatment Quotation or Invoice

Cancelof
Accident Report

An accident report or medical certificate indicating the nature of the external blow is required where claiming for accidental trauma benefits.
Cancelof
Proof of Address

Financial regulations require us to verify your address. Please upload a document dated in the last 3 months that clearly shows the date, your name, and your address. Examples include: Utility bill, Mortgage statement, Salary slip, SARS document, TV license, vehicle license, Retail credit account statement.
Cancelof
ID Document

This must be either your green ID book or your ID card. For the ID card, a picture of both the front and the back is required.
Cancelof
Proof of Bank Account

e.g. Stamped account confirmation letter from your bank. Must be for the bank account details provided in SECTION C.
Cancelof
Photo

Cancelof
SECTION E: DECLARATION
I understand the contents of the completed claim form and I declare that the information given is, to the best of my knowledge and belief, correct and complete. I authorise my dentist to provide Denis Insurance Administrators (Pty) Ltd ("Denis") with information that may be required regarding my dental health. I am aware that some or all of the information contained in the claims documentation will be shared with Foschini Retail Group (Pty) Ltd ("TFG") and Guardrisk Insurance Company Limited ("Guardrisk"), who is the insurer and underwriter of TFG Dental Plan and TFG Dental Plan Family. Furthermore, I agree and confirm that I have read and understood the contents of this claim form. I agree to indemnify TFG, Guardrisk and Denis and hold them harmless against any claims, loss or damage that may arise in relation to or arising out of the insurance policy or in terms of paying the insurance benefit/s to me. I consent to TFG, Guardrisk and Denis processing my information as provided in this form for the purpose of processing this claim and paying the insurance benefit/s to me.
Signature*

Clear
Your Name

First NameLast Name
Date (DD/MM/CCYY)

DayMonthYear
Date
(CALC) Days since treatment date
This is an automatically calculated field
Foschini Retail Group (Pty) Ltd is an authorised financial services provider. Insurance is underwritten by Guardrisk Insurance Company Limited, an authorised financial services provider. Claims are administered by Denis Insurance Administrators (Pty) Ltd, an authorised financial services provider.
OFFICE USE ONLY

This section to be completed by DIA by editing and then submitting the form. Note that you can manually override any of the automatically calculated values.
1. OFFICE: Diagnosis details

OFFICE USE: Diagnosis details (use commas to separate tooth nrs and procedure codes)

	TOOTH NR	PROCEDURE CODE
DEVENT
DACAYS
IMPACT
ABSCES
DENTEM
ACCCH
ACCTF
ACCKN
ORAL
JAW

2. OFFICE: Claims Risk Level
2A. OFFICE USE: is this the 1st claim?

YESNO
2B. OFFICE USE: claims history on same tooth number?

YESNO
2C. OFFICE USE: Is the event claimed the same as the diagnosis received?

YESNO
(CALC) Count: general events (not tooth specific)
This is an automatically calculated field
(CALC) Count: tooth specific events
This is an automatically calculated field
(CALC) TOTAL Number of benefits claimed
This is an automatically calculated field: Tooth specific event(s) + non-tooth specific event(s)
(CALC) Payout value of each event selected (R): general event, tooth specific event
Calculated field based on benefit selection. You can override the value.
2D. (CALC): Is the claim submission within 90 days from treatment date?

YESNO
2E. OFFICE USE: Repudiation may be required: combination of benefits/ > 90days since treatment
Calculated field. You can override the value.
(CALC) TOTAL CLAIM VALUE (R)
Calculate field: Sum of payout for all events selected. Tooth specific events are calculated as (payout * number of teeth). You can override the value.
2F. (CALC) CLAIM RISK LEVEL
Calculate field: you can override the value. NOTE: You will first need to manually complete (1) is this the 1st claim and (2) Is the event claimed the same as diagnosis received. You can override the value. A HIGH risk rating requires authorisation.
3. OFFICE: Checklist
3A. OFFICE USE: Staff member

YESNO
3B. OFFICE USE: Change of personal details

YESNO
3C. OFFICE USE: TFG membership verified

YESNO
3D. TFG Dental Policy Option
Get this from the TFG member verification form
3E: OFFICE USE: days from commencement date
Copy and paste the number from the TFG member verification form
3F. (CALC) Within 90 day waiting period

YESNO
3G. OFFICE USE: Supporting docs received

YESNO
3H. OFFICE USE: Do the bank details provided match those in i2?
If you select NO and Proof of bank account (document upload) has not been provided, email requesting a stamped bank statement will automatically be sent to the email address provided in the claim form.
3I. OFFICE USE: Client risk rating
4. OFFICE: Claim authorisation (High risk claims only)
4A. OFFICE USE: Authorisation Status
4B. OFFICE USE: Authoriser Name
4C. OFFICE USE: Authoriser Signature

Clear
5. OFFICE: office use numbers
OFFICE: Claim Number
OFFICE: Batch Number
Should be Empty:

TFG DENTAL PLAN AND TFG DENTAL PLAN FAMILY CLAIM FORM

SECTION A: TFG ACCOUNT HOLDER'S DETAILS

SECTION B: DENTIST DETAILS

SECTION C: ACCOUNT HOLDER'S BANKING DETAILS

SECTION D: CLAIM DETAILS

SUPPORTING DOCUMENTS

SECTION E: DECLARATION

OFFICE USE ONLY

1. OFFICE: Diagnosis details

2. OFFICE: Claims Risk Level

3. OFFICE: Checklist

4. OFFICE: Claim authorisation (High risk claims only)

5. OFFICE: office use numbers