Nomad Insurance Essential

1
Who is the claimant?* This field is required.
First Name
Last Name
2
What is your plan number?e.g. NI - XXXXXXXX
3
Email * This field is required.
example@example.com
4
Claim number* This field is required.CLMXXXXXXXXX - - found in your claim email
5
Has this claim been appealed before?* This field is required.
No, this is the first appeal
Yes, this is the second appeal
6
What is the reason for your appeal?* This field is required.Please explain why you are appealing the claim decision
0/2000
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Large
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Small
Ok
Ok
7
Do you have additional documentation to support your appeal?* This field is required.
Yes
No
8
Please upload the additional documentation here:👉 Important: Please do not upload documents we’ve already received. This helps us process your appeal faster and reduces unnecessary duplication.
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Max. file size: 10.6MB
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Cancelof
9
I represent and warrant the truthfulness and authenticity of all information provided herein, including the claim and appeal details.* This field is required.
I agree
10
Signature* This field is required.
Should be Empty: