[a | Type of Claim: ] retespazstonsxseose ("] Hoeplaiztontay Cae epenses ] Pos Hospatzaton expanses Pak-Qatar Family Takaful Limited Head Otis: 102-106, Business Arcade, Book 6, PECHS. TOU ‘Shara Fla, Kara, Pasian HEALTH [=a Phone (2-21 481174756, Fax (62-21) «386451 EMTS ARATE rental gees Cota ies Creation | Claimant Name Plan Number: Panicipant (Employer) Name: Plan Start Date Plan End Date: Patlonts Name: Patient's Tekatul Certificate Number: [Patient's Gender []halo Female Date of Birth: [ LUI CNIC Number: Ue | a ‘Contact Address: Phone Residence: Phone Office: Mobile 1. State the nature of the medical condition, injury, line 2. On what date did the symptoms frst occur? || ILL JL 111 3 Name and address of Physician provider fst Consulted due to above-mentioned medial conelition: 4 Has the patent consulted any doctor fo the above-mentioned medical condition? les []No {ree or ect doctor ana nosptal conse, at na, cae of contain, reason for consuaion and treatment provided fname of DectrMospts! | eof Consultation fantom for Conautaion “estment ests 5.18 this claim related to an accident?) YesLINo i-Ves", what was the date ofthe accident? | | IN| I 1111 ‘Give biel detail of where and how accident occurred? 6. GIVE DETAILS OF ANY OTHER HEALTH, MEDICAL OR TRAVEL. TAKAFUL/ INSURANCE, WORKMAN'S COMPENSATION, SOCIAL SECURITY OR OTHER MEDICAL BENEFITS TO WHICH THE PATIENT MAY BE ENTITLED: ae a SS Dat Aeon Da fac [oatnen tao a aaa PR erty cry hat al answers qustons appearing ons lem and cocumurs vd with is fom ar us and coma to tha beet of my bawiodge ans bats [th abeve clamert, hereby authorao any doctor, nasal oe meseal sence prove, ekakineurance company, any oer nit, or Sy porgon wroas ary formate or eco! abate andr any o! my Sepandera fre Pak-Oatar Family Tatu ined w#h fe carla Inlarmaton nea capes of har Yecoes th rlerence to any sexes, ace ata, any westmar,fuaminaon’ mada! Heston, {6ve of heahcae prover. Photocopy alts aubestzaton sha be wald as he onal, oa ot statment: [_[I/_[_ If eopepr cas eaorruneten eter ‘VERIFICATION BY PARTICIPANT/EMPLOYER Wo har caity atl arenes to uostonsappecng ors om ae tue aa oleate beet of mou nowt and et. We wnt ‘and agree tat th aoe alert sha oe bas Taal overage Sinaia ofParicipantin Patient's Name: Father sMusband’s Name: - Z date ot sinh: (| VT TTT) NIC Number: | 1. How long have you been the patient's doctor? 2. On what date were you first consulted forthe injury, iliness or medical condition concerned or for any related condition? 3.Pk 1@ give your diagnosis of the injurylliness/condition? ‘4. Have you any reason to believe that the same or any related condition has. been diagnosed or treated previously by any ether doctor or hospital? 5. Has the patient consulted any doctor for the above-mentioned medical condition? Lives LJNo. "Yes" foreach doctor and hospital consulted, state name, date of consultaton, reason for consultation and treatment provided. ‘Name of DeciorNospital | _ Date of Consultation Reason for Consutation “TrestendReaults 6. Please give details ofthe treatment given or prescribed? 1. Duration of Pregnancy? [list Temaster (Jend Tomeste [ra Timestr = 2 Would normal delivery endanger the ife of mother andor child(ren) and intra-abdominal ‘surgery necessary for extra uterine pregnancy or complications: Ces CN H1"Y0", please ave reason in otal 3. 1s there any permicious vomiting in pregnancy, toxemia with convulsions or spontaneous abortion? yes CINo It "¥ae, please gv reazon in etal ‘DECLARATION ener cuty naa anenere to aestansappening onus om ae te and compete tothe beet mow krowtege and ett date o statement: (TT LL —Sionatare of treting physician Name of Physician PMOC No, ‘Address: Contact No. IMPORTANT: In order to avoid any delay, please ensure that: Use New Ciaim Form foreach claim oF course of treatment “The Individual Covered o ihe logalpresentaves must complet al questions of Part Ao the claim form and sign i ‘The trating physician must complote al qustions of Part 8 ofthe claim form and ign Please recheck and send {uy completd claim form wih ll rtavant documen{s)Repert ko Pak-Catar Family Taka Linted, Please be informed that ‘© Incomplete claim form CANNOT be accepted for processing of payment. (© Engure to attach ORIGINALS of al relovant documentsReport (© Ensure to attach ORIGINAL bis and ecapt of payments). (© PHOTOCOPIES are not acceptable for processing of lai. RERas