CLAIM FORM

Confidential

Policy Holder

Insured Member

Name of Claimant

Bank/Branch

Account Number

CLAIM DETAILS
(a) Nature of illness, Injury, Surgery:
(b) If part of the treatment has already been claimed for, please give the date or reference of the previous claim:
(c) Total Amount Claimed for :

(d) Are you insured under any other Medical/Surgical/Accident insurances? YES □ NO □
If yes, please give details:
Name of Insurer Type of Cover (Medical, Surgical, Personal Contract Start Date
Accident)

CHECK LIST- HAVE YOU ENCLOSED

□ Doctor’s certificate regarding nature of illness?

□ Original receipts and prescriptions?
□ Detailed pharmacy bill?
□ Detailed laboratory invoice?
□ Notation and surface of teeth treated where relevant
□ Details of lenses for optical claims?
□ In case of accident, separate sheet detailing all parties
involved?
Claims will not be considered unless:
(a) The relevant items in the checklist hereunder are enclosed
(b) The claim form is submitted within THREE months (90 Days) of last consultation.
(c) One claim form to be used per insured person per treatment
(d) All relevant sections on this form is duly completed and signed

DECLARATION

I hereby declare that the above statements are true and that I have not withheld any information connected with this claim. I hereby
authorise any doctor, surgeon, medical practitioner, clinic, hospital and pharmacy to disclose to SICOM General Insurenace Ltd any
information regarding this claim.

Member’s Signature Date

Claimant’s Signature Date