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  • Form Medical Reimbursment

    Uploaded by

    Mayani Eliza
    8 views1 page
    The medical reimbursement form collects information about an insured person's medical checkup for the purposes of reimbursing medical expenses. It requests details like the agent's name and code, insured's name and policy number, date and location of the medical checkup, amount to be reimbursed, bank account information, and spaces for approvals and processing notes. The form is used to process reimbursements for medical examination costs associated with insurance policies and proposals.

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    form medical reimbursment

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    The medical reimbursement form collects information about an insured person's medical checkup for the purposes of reimbursing medical expenses. It requests details like the agent's name and code, insured's name and policy number, date and location of the medical checkup, amount to be reimbursed, bank account information, and spaces for approvals and processing notes. The form is used to process reimbursements for medical examination costs associated with insurance policies and proposals.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    8 views1 page

    Form Medical Reimbursment

    Uploaded by

    Mayani Eliza
    The medical reimbursement form collects information about an insured person's medical checkup for the purposes of reimbursing medical expenses. It requests details like the agent's name and code, insured's name and policy number, date and location of the medical checkup, amount to be reimbursed, bank account information, and spaces for approvals and processing notes. The form is used to process reimbursements for medical examination costs associated with insurance policies and proposals.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    MEDICAL REIMBURSEMENT FORM

    Agent’s Name :

    Agent’s Code :

    Life Assured Name :

    (Payor’s name) if any

    Status :

    Proposal/Policy No. :

    Medical Check up date :

    Hospital / Medical Panel :

    City :

    Medical Type :

    Amount to be reimburse :

    Name :
    ‘If Transfer, please fill in the date below

    Bank :

    Branch :

    A / C No :

    Request by date Approved by, Date :

    Agency Group : ________ Agency Executive

    A : Accept, R : Rate Up, N : NTU

    For New Business Department used only


    By:
    Document checked (Y / N ) :

    Amount Payable :

    Comment :

    Acknowledge by :

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