The HR Manager/Head of Medical Section

Human Resource Group, ABL Head Office

Lahore
M EDICAL C LAIM F ORM
I. E M P L O YE E AND P A T IE NT I NF O R MA TI ON
Employee’s Syed Muhammad Hur Hassan Kazmi
Name: Syeda Rimza Batool
Patient’s Name:

EIN: 34093 Patient’s relation to Self Spouse Son

employee:
(Option of parents is
Grade: MG-09 applicable on Clerical &
Non Clerical Staff only)
CNIC: 35202-7796116-7 Daughter Father Mother
Patient’s
Place of Posting: 2nd Floor 6027 Kot Lakhpat Office (KLP) Date of Birth: 28-May-2023
(If claim pertains to spouse then provide details of his/her employment, if employed)
Address (Res.): 737 Street E-15 Topaz Block, Park View City, Lahore
Medical covered
Spouse’s
by spouse’s Yes/No
0331-4391414 Employer:
Cell No.: employer:

II. H OS P I TA LI Z A T I ON AND L A B O RA T O RY C H A R GE S
Nature of Complications after birth (Respiratory Distress and others as per details attached)
Disease(s):

Shaafi International Hospital, Islamabad

Hospital’s Name: Lab’s Name:

(Detail of Hospitalization Charges) (Detail of Laboratory/Pathological Tests Charges)

Hospital Bill No. Bill Date Amount Lab Bill No. Bill Date Amount

IPC-0523-05545 02-June-23 Rs. 140,000

15 Bills as per 03-June-23 - 08-June-23
attached details
Rs. 11,900
052329704 (2 bills
29-May-23 - 30-May-23 Rs. 2,170
as per attached details)

III. M E D IC I NE S /M E D IC A L S U P PL IE S A ND P H Y S IC I A N ’ S C H A RGE S

Physician’s Name: Dr. Iqra Ayaz & Dr. Mian M. Mansoor Afzal
(Details of Physician’s Fee) (Details of Medicines/Medical Supplies Charges)
Particulars Bill No. & Date Amount Particulars Bill No. & Date Amount
Pharmacy Charges (15 Bills 03-June-23 - 08-June-23
as per attached details)
Rs. 26,297

IV. D E C LA R A T I ON
I hereby certify that all information provided by me on this Form alongwith enclosures are true, correct and
complete to the best of my knowledge. In addition, I authorize Allied Bank Limited to make inquiries regarding my
medical claim/family history and I waive my right of confidentiality for the purposes of such inquiries. I
understand that any misrepresentation, overstatement, false statement or omission in respect of information
provided through this Form as well as invoices/bills submitted by me, shall disqualify my medical claim and
further render me liable for disciplinary proceedings. Employee’s Signature with date

Counter Signatures of Immediate Supervisor

alongwith full name, IBS number, date and
Stamp: