Cura Administrators Claim Form

Body:

Cura Administrators Claim Form

INSTRUCTIONS:

Please ensure that the following documents are submitted with this form

Hospital / Doctor Account / Medical scheme statement, reflecting the date of service
Proof of payment of co-payment
Proof of bank account details - not older than 3 months

1 Start 2 Complete

Cura Policy No

Cura Product

PRINCIPAL INSURED DETAILS

Name(s)

Initials

Surname

ID Number

Contact No:

Cell No

E-mail

PATIENT DETAILS

Relationship to Principal Insured:

Self

Spouse

Child

Other

Date of Service

Name(s)

Initials

Surname

ID Number

Contact No

E-mail

Medical Scheme

Option

Member No

Name of Main Member

BANKING DETAILS OF BENEFICIARY

Name of Account Holder

Name of Bank

Branch

Account Number

Branch Code

Type of Account

Transmission Account

Current Account

Savings Account

Leave this field blank

Get in touch

Tel: 010 021 0260
Fax: 086 500 7713
E-mail: gerrie@curaadmin.co.za

Physical Address

829 Rubenstein Drive
Moreleta Park
0044
Pretoria
Gauteng

Get directions

We are an authorised financial services provider: FSP26848

About Us

At Cura we are ready to help you enhance your medical cover without leaving your chosen medical scheme. Enjoy the ultimate in medical cover for total peace of mind. Put the fears for excessive hospital cost shortfalls and unforeseen co-payments for medical services behind you.