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Insurance Claim Form

The Insurance Claim Form allows you to claim insurance benefits or reimbursement of expenses for healthcare services received.

To successfully process your claim, we require some of your personal information and all necessary supporting documents to verify the validity of your insurance and your entitlement to payment. Please ensure that the information you provide is accurate. We will notify you about the resolution of your claim as soon as possible.

If you would like access to general or family medicine services remotely, please complete the E-Consultation Form.

If you would like us to arrange a healthcare service within the Varuh zdravja Network of Healthcare Providers, please complete the Request Assistance Form.

All personal data, including attached supporting documentation, will be used solely for the purpose of processing your claim. The use of this form ensures the secure transmission of data.

I am filling in as the insured person

I am completing this on behalf of the insured person

Insured Person Details

E-mail address

Mobile number

Name

Surname

Date of birth

Tax number(optional)

We require the tax number for the purpose of unique identification.

Permanent address

Contact information is needed to contact the insured person.

Insurance Claim Details

Insurance type

Submission of documents

Click to upload ...

Allowed file types are .jpeg, .png, and .pdf with a total size up to 20MB.

By submitting this claim, I declare that I have reported all circumstances related to the insurance case, that I have submitted all invoices for which I will not claim reimbursement from another insurer, and all documentation related to the insurance case, and that all provided information and documentation are true and complete.

I, the policyholder or the legal representative of the policyholder, acknowledge that the insurance company has the right to access the policyholder’s medical records to verify the legitimacy of this claim. If the insurance company finds any falsification or incompleteness in the information or documentation related to the insurance case, it reserves the right to reject this claim.

I, the policyholder or the legal representative of the policyholder, acknowledge that the insurance company may, up to the amount of the paid insurance benefit and based on this claim, assert a subrogation claim in my name and on its own behalf against a third party responsible for the occurrence of the insurance case or obligated to reimburse the costs of services performed due to the occurrence of the insurance case.

I, the policyholder or the legal representative of the policyholder, acknowledge that the insurance company may, up to the amount of the paid insurance benefit under this claim, assert reimbursement of healthcare costs in my name and on its own behalf, which I am entitled to claim under the mandatory health insurance regulations of the Republic of Slovenia.

I am aware that the Privacy Policy of Vzajemna, where I can obtain all information regarding the processing of personal data, is available at Vzajemna Privacy Policy.

You may also provide consent for direct marketing:

(if you do not select the statements below, this does not mean that any previously given consent has been withdrawn)

Soglasje za neposredno trženje

(optional) By submitting this statement, I give Vzajemna zdravstvena zavarovalnica d.d. (hereinafter: Vzajemna) consent, until revocation, to the processing of my personal data on the basis of concluded insurance contracts, including data included in the form for determining the needs and requirements, my joining the Varuh zdravja programme, participation in prize draws and events organised or co-organised by Vzajemna (runs, marathons and other events), my use of Vzajemna's online services, my other business interactions with Vzajemna, excluding health information, for the purpose of direct marketing, which includes the creation of personalised offers tailored to my interests, economic situation, needs, etc. via regular mail and e-mail, SMS and MMS and telephone. I am aware that I may revoke the given consent at any time. The consent can be revoked by a written statement addressed to Vzajemna zdravstvena zavarovalnica d.d., Vošnjakova ulica 2, 1000 Ljubljana or via the form at vza.si/preklic or at the telephone number 080 20 60. Vzajemna will cease processing based on revoked consent no later than 15 days after receipt of revocation.
Soglasje za obveščanje po elektronski pošti

By submitting this statement, I agree that Vzajemna zdravstvena zavarovalnica d.d. (hereinafter: Vzajemna) informs me at the above e-mail address of all circumstances about which it is obliged to inform me at the time of conclusion and during the duration of the insurance contract in accordance with the Insurance Act or the insurance contract, including closing documentation, written notification of the insurance agent, conducted needs and requirements test, information about the insurance product, information about changes to the insurance company's data, on amendments to the insurance contract, on the exercise of rights and benefits under concluded insurance contracts and other notices and documents from insurance. I am aware that this consent is valid until revoked, that by sending notifications to the above e-mail address, the obligation of the insurance company is fully met, that this consent applies to all my already concluded and future concluded insurance policies with Vzajemna, that I must notify Vzajemna in writing within 8 days of any change of e-mail address, that Vzajemna, will process my personal data in accordance with the applicable legislation and can obtain all information about processing and my rights in relation to protection. I read my personal data in the Mutual Privacy Policy, which is available at www.vzajemna.si/politika-zasebnosti and in branches, so that I can withdraw my consent at any time; I can do so with a written statement addressed to Vzajemna zdravstvena zavarovalnica d.d., Vošnjakova ulica 2, 1000 Ljubljana, or via the form at vza.si/info or by phone on 080 20 60.

By clicking the "SUBMIT" button and verifying your email address and mobile phone number, the insurance claim will be successfully submitted. The policyholder will be contacted as soon as possible regarding the processing of the insurance case.

Insurance Claim Form

Information about the Applicant

Insured Person Details

Insurance Claim Details

Note: Valid only if completed by the insured person

Note: Note: Credited towards future premiums (only in case of payment by payment slip).

Documents

Note: Valid only if completed by the insured person

Note: Note: Credited towards future premiums (only in case of payment by payment slip).

Documents

Note: Valid only if completed by the insured person

Note: Note: Credited towards future premiums (only in case of payment by payment slip).

Documents

Note: Valid only if completed by the insured person

Note: Note: Credited towards future premiums (only in case of payment by payment slip).

Documents

Note: Valid only if completed by the insured person

Note: Note: Credited towards future premiums (only in case of payment by payment slip).

Documents

Note: Valid only if completed by the insured person

Note: Note: Credited towards future premiums (only in case of payment by payment slip).

Documents

Note: Valid only if completed by the insured person

Note: Note: Credited towards future premiums (only in case of payment by payment slip).

Documents

Note: Valid only if completed by the insured person

Note: Note: Credited towards future premiums (only in case of payment by payment slip).

Note: Valid only if completed by the insured person

Note: Note: Credited towards future premiums (only in case of payment by payment slip).

Dokumenti

Note: Valid only if completed by the insured person

Note: Note: Credited towards future premiums (only in case of payment by payment slip).

Documents

Note: Valid only if completed by the insured person

Note: Note: Credited towards future premiums (only in case of payment by payment slip).

Documents

Registration Activation