report claim - pfa health insurance

If you need examination or treatment of a physical injury, please fill out this form.

Phone
*
E-mail
*
Civil reg. No.
*
Child's civil reg. No.
If the claim concerns your child
Yes
No
*
*
Yes
No
*
Yes
No
*
What has your doctor referred you to
*
*
*
Date of the first symptoms
*
Please describe the symptoms
*
Yes
No
*