Health claim notice Claim notice Event information Name of the person who received treatment* Personal identification code / date of birth of the person who received treatment* E-mail of the person who received treatment or of their representative * Telephone number of the person who received treatment or of their representative* Name of the health service provider* Date of receipt of health service* Mark the treatment you received Outpatient treatment Amount* Inpatient treatment Amount* Prescription medications Amount* Prenatal care Amount* Dental treatment Amount* Vaccination Amount* Spectacles, lenses Amount* Prophylactic examinations Amount* Treatment of critical illnesses Amount* Rehabilitation prescribed by a doctor Amount* Other medical treatment Amount* Additional information File upload (total maximum 30MB) File upload For example, the treatment invoice should be accompanied with: An extract from the medical history or from the national patient portal digilugu.ee in the case of examinations and analyses In the case of dental treatment, the invoice listing the dental treatment services and issued to the name of the person who received the treatment In the case of rehabilitation, an extract from the national patient portal digilugu.ee or from a decision of an occupational health doctor on the need for rehabilitation Upon applying for indemnity for glasses, a document certifying a change in visual acuity and the expense receipt of the glasses – Remove file + Add more files Indemnity Name of the beneficiaryOnly the insured person can be the beneficiary Bank account number of the beneficiary * I confirm that the information given above is correct and complete. I am aware that the insurer has the right to reduce or refuse to pay out the indemnity if I have knowingly given incorrect information. I agree that the insurer has the right to request additional information concerning the loss event from people who possess such information. Your claim report is sent to ERGO claims' processing department. The notice will be forwarded to the claims handler. We hereby inform you that the time required for making decision is up to 10 working days following the receipt of all necessary documents and information. If necessary, we will contact you before making a decision. In case of additional questions please contact us at email@example.com. There was an error during data sending. We are sorry. There was an error during data transfer. Please send your request directly to the email firstname.lastname@example.org.