Find a form

Select a claim form from the links below. If you need help on which form to use for your insurance claim, visit our “Make a Claim" section. Here we have outlined the process and the documentation requirement for every type of claim with MetLife Alico.

Note: If your request involves a wire transfer of funds, kindly refer to our section below on instructions to receive your funds by Wire Transfer

• Accident Benefits - Employer's Statement (English) / (Arabic)
• Baggage Delays / Baggage Loss Claim Form
• Beneficiary Endorsement
• Final Proof of loss
• Flight Delays Claim Form
• Partial Disability / Accidental Dismemberment Claim Report – Physician & Claimant Statement Form - Form CL-20
• In Patient Medical Reimbursement Claim Form
• Permanent Total Disability – Claimant Statement - Form 321
• Permanent Total Disability – Physician’s Statement - Form 322
• Proof of Death – Claimant Statement - Form CL-39
• Proof of Death – Physician’s Statement - Form CL-40 - (English) / (Arabic)

You can use the insurance forms provided here to amend your existing policy or to take advantage of some of your MetLife Alico policy features. Download the appropriate form, complete and sign the same and then just mail it to our Customer Service Department at MetLife Alico.

Send the form to
Customer Care
MetLife Alico,
Crescent Tower Bldg, 15th Floor,
PO Box 5984, Sharjah, UAE.

Note: If your request involves a wire transfer of funds, kindly refer to our section below on instructions to receive your funds by Wire Transfer

• Change of Address Form
• Declaration & Undertaking regarding a Lost Policy Form (English) / (Arabic)
• Policy Loan Request Form (English) / (Arabic)
• Policy Maturity and Release Form (English) / (Arabic)
• Policy Partial Maturity and Release Form (English) / (Arabic)
• Policy Partial Surrender and Release Form
• Policy Surrender and Release Form
• Premium Allocation Form
• Request for addition of Recovery Benefit Plan Rider
• Request for Policy Change - Life (Change of Name, Beneficiary, Method of premium payment) (English) / (Arabic)
• Request for Policy Change - Personal Accident (Change of Name, Beneficiary, Method of premium payment)
• Request for Transfers Between Sub accounts
• Specimen of Signature

If you hold a MetLife Alico policy through your employer, use the forms provided below to make a claim or to request a pre-determination approval. Please note that some of these forms may require verification by your HR Department.

• Indemnity Medical Claim Form
• Individual Enrollment Form
• Pre-determination Approval Request Form

• Home Delivery Order Form

After you have completed this form, please send it, along with the prescription to metlifealico@asterpharmacy.com or fax it to: +971 42672946.

Circulars

The following documents are for your information and reference only

HAAD Requirements Form for Group Medical Policies (designed by MetLife Alico): This document provides you with all the information you may need to update the records for all your existing employees / dependents as well as any future employees / dependents.

Note: If you have any undeclared members who should be enrolled under a HAAD compliant scheme, kindly provide the required documentation as explained in the above document and send it to your respective insurance consultant’s email address.

HAAD Circular no. CEO/254/11: Document explaining the process related to Dependent Violation

HAAD Circular no. 32 (English) / (Arabic): Document providing details about the Certificate of Continuity of Health Insurance Scheme Coverage

HAAD Circular no. 35 (English) / (Arabic): Document providing details for the Issuance and Renewal of the Health Insurance Card

HAAD Circular no.41: Document providing details for the Issuance of the Health Insurance Card to newcomers

Forms

The Forms, when completed, should be sent to your Insurance Consultant's e-mail address.

Declaration Form (to be signed, dated and stamped by your company): A mandatory form to be completed upon renewal for existing policies and on inception for new policy or new subgroup.

Undertaking Letter (to be printed on your company's letterhead): A document requested by HAAD to be completed by the employer or the sponsor for each "newcomer".

Dependent Violation Appeal Form: A HAAD document to be completed when appealing for a dependent violation

Updated Electronic Data Interchange (EDI): To be completed when amending any detail on the policy such as addition/deletion of an employee or dependent, salary update, etc...