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Forms

All the forms you need in one convenient place

This section contains all the forms you need to report a claim and expedite processing


 

We try to make the claims process as easy and stress-free for you as possible. That's why we have created a few forms that you can submit to claim a refund for your hospital and outpatient care expenses. They also contain additional information to help expedite the processing and payment of your claim.

1) Medical expenses incurred in connection with a hospital stay or to treat a critical illness

Fill out the "Procedure for submitting medical expenses" form and send it in along with your receipts.

2) Claims report form

No third-party payer agreement? Fill out this form to report a hospital stay

3) Outpatient medical care

Fill out the "Procedure for submitting outpatient care expenses" and send it in along with your receipts.

4) Application for continuation coverage on an individual basis

Lost your right to your corporate healthcare plan? Use this form to apply to continue your cover.

Send in all receipts to :

AG Insurance
Health Care Department
Boulevard Emile Jacqmain 53
1000 Bruxelles

or

health.corporate@aginsurance.be