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  • Insurance Claim Form

    Uploaded by

    Tanvir Ahmed
    7 views2 pages
    This document provides information for a guardian claim. It includes sections for the name and ID of the guardian, patient details like name, relationship to guardian, and medical history. Treatment cost details are broken down by hospital accommodation, consultation fees, medicines, medical/operation charges, and tests. Account information like bank name and account number are also included. The form requires signatures from the employee/claimant, department head, and plan secretary to process the claim. It notes that additional documents may be requested by the claims department if needed.

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    Original Title

    Insurance_Claim_Form

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    This document provides information for a guardian claim. It includes sections for the name and ID of the guardian, patient details like name, relationship to guardian, and medical history. Treatment cost details are broken down by hospital accommodation, consultation fees, medicines, medical/operation charges, and tests. Account information like bank name and account number are also included. The form requires signatures from the employee/claimant, department head, and plan secretary to process the claim. It notes that additional documents may be requested by the claims department if needed.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    7 views2 pages

    Insurance Claim Form

    Uploaded by

    Tanvir Ahmed
    This document provides information for a guardian claim. It includes sections for the name and ID of the guardian, patient details like name, relationship to guardian, and medical history. Treatment cost details are broken down by hospital accommodation, consultation fees, medicines, medical/operation charges, and tests. Account information like bank name and account number are also included. The form requires signatures from the employee/claimant, department head, and plan secretary to process the claim. It notes that additional documents may be requested by the claims department if needed.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    Guardian

    (Please Use Block Letter)


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    Name of Organization: StafflD No.:
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    Name of Staff:

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    Mother Husband Wife Son Dauqhter
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    Date of Prior lntimation: Membership No.:

    Date of Admission:

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    Medical Test and Ancillarv Services:
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    Accounts Related lnformation

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    Bank Name & Branch:

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    A/C No. & Routing Number

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    Ref No. : Date

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    Signature of the Employee/Claiment Signature of the Dept./Div. Head with Date Signature of Plan Secretary with Seal
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    N.B.: lf requires claims department may call for any further documents.

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