2811700 - Clone of TFG CLAIM FORM

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) to: Fax: 0866 737 336 email: TFG@denisinsurance.com
I am submitting a claim for:*

MyselfMy PartnerMy Child
Partner Name

First NameLast Name
Child Name

First NameLast Name
SECTION A: TFG ACCOUNT HOLDER'S DETAILS
TFG Store Account Number*
Name*

First NameLast Name
Date of Birth

DayMonthYear
Date
ID Number*
Email Address*
example@example.com
Cell Number*
Please enter a valid phone number.
Postal Address

Street/ PO Box

Street Address Line 2

CityProvince

Postal Code
Province
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
Date
Practice Number*
SECTION C: ACCOUNT HOLDER'S BANKING DETAILS
Initials and Surname of the holder of this bank account
Bank
Account type
Branch Name
Branch Code
Bank Account No.
SECTION D: CLAIM DETAILS

The insured event for which you are claiming.
Are you claiming for a day to day event? NOTE: 3 month waiting period

YesNo
Are you claiming for an emergency?

YesNo
Are you claiming for an accident?

YesNo
Are you claiming for oral cancer? NOTE: Pre-existing conditions excluded

YesNo
Are you claiming for a jaw fracture? NOTE: Pre-existing conditions excluded

YesNo
Select one (if claiming for day to day)
Select one (if claiming for emergency)
Accident Type (if claiming for an accident)
Give a brief description of the accident (if claiming for an accident)
Tooth Chart Draw on Image: circle the tooth/teeth affected
Select the applicable tooth number(s) with reference to the tooth chart above

11 Upper Right Central incisor21 Upper Left Central incisor31 Lower Left Central incisor41 Lower Right Central incisor12 Upper Right Lateral incisor22 Upper Left Lateral incisor32 Lower Left Lateral incisor43 Lower Right Lateral incisor13 Upper Right Canine / cuspid23 Upper Left Canine / cuspid33 Lower Left Canine / cuspid43 Lower Right Canine / cuspid14 Upper Right 1st premolar / bicuspid24 Upper Left 1st premolar / bicuspid34 Lower Left 1st premolar / bicuspid44 Lower Right 1st premolar / bicuspid15 Upper Right 2nd premolar / bicuspid25 Upper Left 2nd premolar / bicuspid35 Lower Left 2nd premolar / bicuspid45 Lower Right 2nd premolar / bicuspid16 Upper Right 1st molar26 Upper Left 1st molar36 Lower Left 1st molar46 Lower Right 1st molar17 Upper Right 2nd molar27 Upper Left 2nd molar37 Lower Left 2nd molar47 Lower Right 2nd molar
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. 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.
Treatment Quotation or Invoice

Cancelof
Accident Report

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 Address

Document must have been issued within the last 3 months. Examples include: Utility bill, Mortgage statement, Salary slip, SARS document, TV license, vehicle license, Retail credit account statement.
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
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.
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