Prescription Drug Reimbursement Form

Seafarer Information

Name

First

Last

Date of Birth

Union Reference Number

Found in your SIU Membership Book

Phone Number

Email Address

Union Number

Found in your SIU Membership Book

Residential Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Employment Information

Employer Name

Name of Last Ship

Patient Information (if different from policyholder)

Name

Date of Birth

If any of the claims indicated below is for the Seafarers' spouse, is he/she covered by any other insurance for this type of claim?

Yes
No
Not applicable

Relationship to Policy Holder

Address (if different)

Is the seafarers’ spouse also a seafarer?

Yes
No

Amount (claim Paid

Drug Claim Information

You can upload up to three separate claims below for a single individual. If you are filing a claim for multiple individuals, please file them using separate forms for each person/claimant.

Claim #1

Name of Pharmacy (claim #1)

D.I.N. (claim #1)

If you are submitting a claim with multiple prescriptions included, please separate each DIN number with a comma.

Prescribed Dosage (claim #1)

If you are submitting a claim with multiple prescriptions included, please separate each prescribed dosage with a comma.

Upload Invoice / Receipt (claim #1)

Drag & Drop Files, Choose Files to Upload

Date of Purchase (claim #1)

Name of Medication (claim #1)

If you are submitting a claim with multiple prescriptions included, please separate each name of medication with a comma.

Total Amount Paid (claim #1)

Claim #2

Name of Pharmacy (claim #2)

Date of Purchase (claim #2)

D.I.N. (claim #2)

If you are submitting a claim with multiple prescriptions included, please separate each DIN number with a comma.

Name of Medication (claim #2)

If you are submitting a claim with multiple prescriptions included, please separate each name of medication with a comma.

Prescribed Dosage (claim #2)

If you are submitting a claim with multiple prescriptions included, please separate each prescribed dosage with a comma.

Total Amount Paid (claim #2)

Upload Invoice / Receipt (claim #2)

Drag & Drop Files, Choose Files to Upload

Claim #3

Name of Pharmacy (claim #3)

Date of Purchase (claim #3)

D.I.N. (claim #3)

If you are submitting a claim with multiple prescriptions included, please separate each DIN number with a comma.

Name of Medication (claim #3)

If you are submitting a claim with multiple prescriptions included, please separate each name of medication with a comma.

Prescribed Dosage (claim #3)

If you are submitting a claim with multiple prescriptions included, please separate each prescribed dosage with a comma.

Total Amount Paid (claim #3)

Upload Invoice / Receipt (claim #3)

Drag & Drop Files, Choose Files to Upload

Authorization and Consent

Consent

I hereby certify that all of the above information is true and that the documents submitted herewith are authentic. Should any of the same documents submitted on my behalf be found to have been falsified, I will be liable to suspension of further benefits.

Policyholder's Signature

Clear Signature

Date of Signature