NOTIFICATION OF ILLNESS INSURANCE EVENT

1.From……………………………………………………………………………………………. telephone ……………………

Address ………………………………………………………………………………………………………………..

e-mail:……………………………….……….………………….………………mobile…………………………….

Workplace ………………………………………………………………………………………………...…………………….

PIN / Insurance№

The claim relates to:

еmployee / family member

2. The notification is submitted by a legal representative or authorized person:

Full name on ID card:………………………………………………………………….

tel. ……………………

PIN:………………………………

Address or e-mail:..……………………………………………………………………………

The notification is made by an insurance broker:

Name:…………………………………………………………………………………………………………………..

Address and telephone:…………………………………………………………………………………………………

I would like to receive the sum amounting to ……………..BGN /in letters ...... / ... as a reimbursement in accordance with the Agreement for health insurance, the purchased plans for health services and the General provisions in regard to them

bank account IBAN

B / G

Account holder / full name on ID card / PIN

……………………………………………………………………………. ………………………………

I am aware that any false statements and documents bear criminal responsibility under Article 313 of the Criminal Code.

I agree UHIF "Doverie" SA to process my personal data (or the data of the a person under 18 years insured by me referred to in this notification, under the Law on protection of personal data in connection with the procedures and administration of my claim for insurance compensation.

By providing a mobile phone number and e-mail address I agree to receive text messages about the procedures related to notification. I am familiar with the ability to refuse receiving such messages by confirming my refusal in writing by e-mail: ozof_doverie@abv.бг

3. I attach the following documents:

(Please encircle the documents you present and note their number)

1.  Medical document / ambulatory or medical history sheet / describing the disease for which the relevant medicines and supplies are prescribed or a treatment is conducted - ………………………………………………number.

2. Recipe for prescribed medicines and / or medical devices …………………………………………number.

3. Original invoice and cash register receipt ……………………………………………………………….number.

4. A copy of the bank document confirming the veracity of the holder of that bank account.

5. Other………………………………………………………………………………………number.

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

I am aware that the deadlines provided for in Art. 107, par. 1 of the Insurance Code start running only with the submission of the documents specified in Article 21 of the General provisions of UHIF “Doverie" SA.

Date...... Signature………………………………

Insured / Authorized person

4. The documents accepted: ………………………………….employee Note…………………………………….

Date………………

INSTRUCTIONS

ABOUT

І. COMPLETION OF NOTIFICATION FOR COST REIMBURSEMENT

The notification is completed personally by the Insured or his/her representative:

In item 1. The full name of the insured on ID card, PIN, current mailing address, telephone, mobile phone and e-mail. Under the Agreement for group medical insurance in the column "Workplace" shall be written the name of the company contracted for group medical insurance. With the sign "X" shall be indicated if the insured person is insured as an employee or as a family member.

In item 2 if the insured person is under 18 years of age or the notification is submitted by the legal representative shall be filled the full name of the legal representative or the authorized person by ID card, PIN, current mailing address, telephone, mobile phone and E-mail.

In item 3 are described the documents submitted with the notification. The items in the list of submitted documents shall be encircled, and their number of documents shall be written. Only original invoices and cash register receipts shall be presented. In the column "Other" shall be described other documents proving the insurance claim.

ІІ. SUBMISSION OF NOTIFICATION FOR COST REIMBURSEMENT

1.  The Insured (or his/her legal or authorized representative) shall inform UHIF "Doverie" SA for the insurance event by filing a written notification of the damage as indicated in the sample application form of the Insurer.

2.  The notification shall be submitted directly or by the agent mentioned in the Agreement in the office UHIF "Doverie" SA or by mail and courier service: Sofia, ul. "Lachezar Stanchev" № 5, “Sopharma Business Towers” Complex, building A, 5th floor

3.  The Insured (or his/her legal or authorized representative) shall make his/her claim within 30 calendar days of the occurrence of the event, unless another period is not referred to in the Agreement for medical insurance. If the Insured fails to meet this deadline for valid reasons, the Insured shall explain the delay in writing.

4.  The UHIF "Doverie" SA employee receiving the notification checks for the correct spelling and complete data on the insured ID card and health insurance card and the compliance of the attached documents with the notification.

ІІІ. PROCEDURE FOR COST REIMBURSEMENT

The INSURER shall pay the INSURED person the determined amount of reimbursement in accordance with the agreed insurance amount within 15 (fifteen) days from the date of submission of all necessary documents. The money is put into a bank account specified by the Insured.

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