Tha sue ofthis Farm is alte be akon as 2 asin ot aby (Tabet ndacletes)
DETALS OF RMA SURED:
sews QOOODOOOOOOOOOOOOOOOO ses QOOOOO0000
aamreve QOOOOOOOOO0000000
OQOODSSOHE000000 000000000 000E0080000800000
ewes: OO OODODOOOOD0DO 00000 000000000 000000000000000 z
OODOUOOOO0OU DOOO0000000000000000000000000 2
@ OOOOO00000000000000 oo0000000000000000u0 5
|
eee 00000 ~ OOOOO0000d se
acowtyoeubyersmeiinttaih hace To [te SOmctoremenmcttstherme wate JE] LE LL nearer a
arson OOOOOOO000000 » OOO00O00R0000000000o
sunset CICIDIDIID cieeybseresptaccincmwstyeastC] vs Ove ome] EID) owed
srewiomymacicamionmee: Cs Oe — inmcmnne IODOOOOOCOOOCOUCoooo
eee QODOSS0SS0000 000000 000000000u02b22E0e000080000
2) owe we Ore cel] om OE omen OE ON OO
afatcraperimayesiee Sat E] SeaeC] OME) raw] semw C] ote [] penesqey) [>
4) owaipton —Sevce C]SaEreoed C] omens] stent] ated CE] ober C) ireesesveaty [SSCS—~*™
AMwutewetotes OOOOIIUOIOOUODOUOOOOOOOSSSSGS0000000 s
DOOOOCS00000000000000000000000000000008000 s
QODOOOCO00000000000 OO00000000800800005
reese 00000 - OOOOOS00000 se —
1S 2 NOLS TY
otmnctiomieeemiet COO OODOO GOO COO COOoooooooooooooooooG
fem cage eee Doe C] Siew heats Seamer
i Momptazsten unis: Iny C)trese CJ atrnty C] ADechu/IthOinimcOoy OL OO OO
somdsimn EIS) 60 GE aD ao
(tmuyemens Steed C] St nC] utente he
irpeweopte Cie Ce jpn! ae
DETALSOF CLAM:
‘Ona teeter chit
Propataten psaes &OOOOOOO ‘tice: 8. QOOO0OO _
cottincome: OOOO «twmomcwrce — SOOO OOD | 6 cvsrecsmanin
Arann ee ®OO00000 «sees OOO = OO00000 | = “eee
Tota ® DOOOOOO | 9 si.
1, Pretapalen pret eQ00 wroteon: os OOO “eral BIPavns Faso
‘orp Sunray
2) chimtrDometnytopttei: Eves E]No des oie catsin ar) So
ja t.ump sunt cash ee cs: om vs
espe Datyca ® OOOOOOO ‘ssstarcm ® OoOoooog] 2
Wnt ten ee: = DODO OOO «cine: fs ODIO | ose reeteresiain
verrcneniateteowen's QOOOOOO vo OOO» OOOOOOd | § liege
D benrsPreretc
Teta ® DODO | 6 oes
DDETALS OF BLS ENCLOSED:
Sime | BiINe ued by ‘Aout
TS TTT NCS NCSDECLARATION BY THE INSURED:
hereby decte that
“uapressn oreonealnent of ary materal net my rata cain reimbureemer
‘Annexure -
cf my kroutadge abet have made ay fle or uns statement
‘alle orieted alo consent & authorize TPA inuranee company, sea necessa7y
sé onthe parson sane! warn is lin is ade, hereby detare ta! have
Irluded alltel recipi forthe purpose ols cam & at wl rate making ary supplemeriary cam exceat th arepor-nestaiatin ea #8.
«EE Oa
[DD Pece | sara tte sue
‘GUIDANCE FOR FILLING GLAM FORM PART A(T be filedin by he Inewea)
‘SECTION A- DETAILS OF PRIMARY INSURED
a Paley
rir the poy number
Beale bythe houranee coneary
2) _SLNo! Conieate No
niet soil Insrarc8 TURBO Oe CORTES TOT
scealnealtinsraneeseheme
‘As aleted by the egeizaion
e056 PATER ae ToT By TRO Sr
briniadin TPA dooumont
ome
riers adeess
Trclude Suet Cty and Pa Code
3 Cae EoeT0 BY A OAT STITT HAT
Teens whore caver covered By arabe Wed
2) CompanyName Erie ul rae ofthe maureen coma Nene othe orgaizaton nl
Poteye Enirthepeey number ‘alt bythe rsuranen coma
Sum are Ener ol sim eurod as porte bole Tripees
ate Erie da of hosptalaton Use many toa
Diagrase rire deghess dtals Open Text
I Previa Covers By any aar MOGCRAT Heal | Teeate whether provevaly covered by arate MEGERTAT —|riex vor orn
Inswanes? Heals surance
TL Cameany Name
Name Erie ul name ofthe pallet Surname, Fat name, Male nae
3) Gender Treat Gender ofthe patient Tick Wele or Female
ci Enier age ote plot Number of wars and one
2) Reatenshipia inary haured Treaterelatnshipo paler wih oaleyolae Tick igh opto, ahes ease sped
i) Oeevpaton Teese eeeupaon of patent Tick gh option Wotar, oleae sec
a Aeros Erie te ullpestalaaeoss Tpclude Suet Gyan Pa Code
hy Phone Ne Enierthe shone nob of aon Treluge STO code wih lphone nob
1 Ema Eniere-nalederess of pation Copies esi saee35
‘SECTION D- DETAILS OF HOSPITALIZATION
are of Howat where sae
Erie ware of hpi
Tae of Faspre n
2) Room extopry ocepied
Treats ho room category occupied
ei Horeitateaten au
Teese razor of spialiaton|
“FDala of FjuyDate Daeave Wat erected Dale
Use dy format
Toe niet of adieion ‘se hen ora
One of dearer Erie die of ena Use dry format
Tick ah anton
Mek eg
Treats whether ity mode egal
Tick Ves or No
Feperedto Pelco
Tres whether poles report was ed
TiekYororNo
MLC Ropon& Pelee Fi aachod
Teese whorer WLC repr ara Poti FIR aero
Open Tew
SECTION E- DETAILS OF CLAIM
@_Dealsal Teamen Expenses
riers amount med as testmert amperes
Trrupees (Do rot eter pave value)
2) him for Doin Hesprazaton
Tren whether nm for dora sphaliafon
Tiek Yor orNo_
=\_Detl of Lump son ens bert eaimed
niet amount chimed a mp sum eng bone
Treate whieh svppoing dbeurens are subried
Tek igh apton
‘SECTION F- DETAILS OF BILLS ENCLOSED
Tndale Wilh bill are onclosed wah ihe GmGusEs NVUDoee
MH NOWLO3S