Allianz @) @ Claim Form Important tstRUCTIONs: (please read them Nfs) I norder for us to provide fast and efficient service, please complete the Form accurately in CAPITAL LETTERS. Photocopies ofthis form can also be used. I illed forms should be sent to: thn 30 dy ole pense heed One Pes: aac te eloang wt etm Proper itemized bill) and payment ecept(s) as highlighted below. These should be isued onthe oficial blfecept book of the Hospita/Physcar/Surgeon/PharmacyLaboratory. Proper hospital bin original highighting type of accommodation used (room type) and break up of total bil according to: Room charges @ Lab tess and Radiology Charges. @ Consultation charges @ Surgeons fee with details (i any) © Operation Theatre Charges (any) @ Anesthesia charges (any). © Mecicines (used during hospitalization) Other miscellaneous medical expenses like blood & oxygen, etc Laboratory, or Radiology report along with doctor's reference forthe same. itemized bills) of medicines purchased supported by Physicians prescription specifying the quantity and respective dosage Hospital discharge summary / Clinical Summary (in case of Hospitalization), €. Copy of ith Certificate (in case of delvery/cild birth) UL you have any fits filing this form, please al our Claims Dept. at 111-HEALTH (021-111-432508) Approved claim could be settled through direct bank transfer. Please provide following bank details for direct bank transfer, aoe Name ofthe Policy Holder Policy Number: Name ofthe Employee: Cert. td Name of Patient Total Amount Cimed: | Rs. Date of Bit Relationship to the Employee Bank NIC Number (an Branch: Department NC No: Contact No: Ena Detail of New Born (s) In Case of Delivery C-Section Claim: Date of ith: Name: cender: {In-case of Hospitalization: Emergency Treatment or Elective? Was preauthorzation token? C1Yes_0 No Date of Admission: Date of Discharge: Is the patient entied to anyother beneft or compensation from any other source whatsoever? If so name the companies of association ‘or other source, and give amount of benef payable by each Declaration / Authorization: "heey cart that arses, and all dcurens subited with he cn fon ar cele and tue. hereby autor ary do, spit dior medical provide, {ay iauanee company or any company, inition or any aber person who has any rear ot nlermation about me snd of my family merbes to provide ‘en EU Heath surance Lite wt the infomation, indudng copies ote recods wah eeseceto any sickness races, any teste, xaiatin ice ‘or hospalaton. Ary pty ofthis destan authorization shal be olen 3 the og op. Signature of Patient Signature & Seal of the Employer Date (G18 years above athens signe cf the empl) (Por orate cers on)iy TT Ty cnn Patient Name Ae Gender C) Male CFemale ame of Hospital Date of Admission ‘Dse of Discharge Primary Diagnosis Secondary Diagnosis Presenting Complaints With Duration of tlness Ay Associated Disease / Comorbids With Duration Debils of Surgical, Gynecological or Obstetrical Procedure Performed (if Any) Indication / Necessity of Performing Surgical Procedure/ \SCS Type of Anesthesia Used: C1General Cllocal Cispinal Ci other: {hereby certify that my answers tothe foregoing questions are corect and true, tothe best of my knowledge and belie. Signature & Stamp ofthe tending Physica: Name & Address Phone Number: Fox Credentials Qualifications: Date: For Allianz EFU Health Insurance Use Only ' t 1 cyte cant Chaim Received On: aim Approved 8 Allianz EFU Health Insurance Limited Pakistan's First Specialized Health Insurer Cerificate Number: ‘Ashorzaton Number (Cairn Emre By ‘Gaim Cheque Dispatched On: 1-136, Blok, KDA Schemes, Clifton, Karaci7560. Phone: 11-HEAITH (11-452584); Cal Cente: (21) 111-HELP-00(11-4357-00); Fax (6221935064020 Email daims@alianzafucom