NCIA - Online Helpdesk

Claim Request Form

Company Code:

Name of Principal

Patient Name (principal/dependent)

Birth Date

Date of Availment

Product

Provider

Type of Claim

Remarks / Reason for Claim

Contact Number

Email Address 1 (member)

Email Address 2 (optional)

SUPPORTING DOCUMENTS

INSTRUCTION: Please ensure that all relevant supporting documents are prepared before submitting your request. After clicking the Submit button, a confirmation pop-up will appear prompting you to upload the available attachments. If you are unable to upload all documents at that time, you may still upload the remaining supporting documents using the upload link provided in the confirmation email. All additional document submissions and information exchanges will take place within the same email thread. Accepted file formats: PDF, JPG, JPEG, PNG.