N @UiMterican LIFE INSURANCE OP TRINIDAD ANDTORAGO HEALTH INSURANCE CLAIM FORM. Clans ust be submited win 9 aye of beng incured and cg ecctsitozed bits must be atch, ‘TO BE COMPLETED BY EMPLOYEE / INSURED: surname: Fist Name: Date of rth: (mye: Address: Patient's Name Date OF Birth: (mye). When dd symptoms of the allment ist ppe9r2——————— Have you ever had this alment before? If yes tate when and dsb = ‘CAUSE OF CONDITION: ‘CO-ORDINATION OF BENEFITS: Ispatientsconditionrelatedto:(e}Employment? C] Yes [No Ispatientcoveredby anyother planswhichprovidebeneisforthisinuny (eyrutonccident? ves Co corsichness? Ces Cno (oothersccident? Ces Ono Itesigive _@)NameOFlnswenceCompany—__________} (brnsureds Name. ee (@NameofGrouporCompany Insured Under tt¥esStateNameofEmployersinsurer AUTHORIZATION: [ASSIGNMENT OF INSURANCE BENEFITS: ‘Uwehereby cect thatthe foregoinganswersaretrucandcorrecttothebestof | therebyauthorizeanddvect youtopayta mmylourknowledgeandhereby authorzealldectrsorotherpersonswho — ‘reatedmeandallhospitalzorotherinsttuionstofurishfulldetaled allbeneftsduetoms ormycoveredde pendants) asaresutofthsclaim. information inching flloplesofthetr records) regardingthisclaim lunderstandthatlam financalyresponsibleforchargesnotcoveredbythe Palsy. Insured Signature; Insured Signature SpousssSignature ate: eae ate: — 2.70 BE COMPLETED BY EMPLOYER / POLICYHOLDER: PolicyHolder Polley: Employee cetifieateN ectiveDate HasemployeemadeclsimforWorkmensCompensation? (] Yes] No Ishe/sheentiledtosuchbenefits? ves One Companysstame: AeminsratorsSignature ate. 3.70 BE COMPLETED BY OPTICIAN/OPHTHALMOLOGIST/OPTOMETR!S Patient's Name: Date OF iets (iyr) Diagnosis Date of Service| Desription of Service charges amiyr Dsinete © Cevfoca, Cl muenirocal Cluenmcurar Ci contacruewses Cl sunctasses Toma | HEREBY CERTIFY THAT THE ABOVE SERVICES AS INDICATED BY DATE HAVE BEEN COMPLETED STAMP “JGNATURE OF OF CANSGPHTHALNOLOGIST/OPTOMETRIST DATE Pan-American Life Insurance Company of Trinidad and Tobago, Ltd. 91.93 Stvincent Street|Por of Spain, Republic of Tinidad & Tobago Te: 868 6254476 Fax:868.6234923|pallgcom camo. osm age of1. TOBE COMPLETED BY DOCTOR / HEALTH PROVIDES Patient's Nome: ate OF Birth: (mye) Date of Vit DiognorisACD Code visit frypeof Service Rendered cot | Further services orService fee_|vict™ | (drugninjections test supplies) Recommended Date of fist symptoms: Hos patient been previourly rated for this condition? Lves LIN. Date offirstconsutation for thiscondition Yes cive date os pation refered? i Yestatate name fof don eee ‘SURGICAL PROCEDURES Date ofSurgers Surgeons Fee § Describe Procedures Performed: Asst Surgeon's Fee § Anzesthetist’sFee_$ Date of Delivery or Termination Type of Delivery: ObsteticalFee § (MATERNITY Date Pregnancy Commenced/LMP | HEREBY CERTIFY THATTHE ABOVE SERVICES AS INDICATED BY DATE HAVE BEEN COMPLETED STAWP SIGNATURE OF DOCTOR/HEALTH PROVIDER are 5.70 BE COMPLETED BY DENTIST: Patient’ Nam penmise_ TeL No; ___ Date OF Birth: (miye) aitstreatment a result of occupationalilnessorijury? ChYes CL No (Details tyes (es treatment a resultof auto accident? Ores Ono (0 Other accent? Des Ono LUST OF SERVICES (USE CHARTING SYSTEM SHOWN) DatooFservice | Toowe | Surecet) Deicipton of Senice charges (dime) | orteter TOTAL, ‘ORTHODONTIC TREATMENT CROWNS INMAL DENTURES OR BRIDGES (a) Date offs appliance: _____a)isthis anni placement?________isthisan initia placement (b)Dateotleseapplance: —__(e)Reasom: Date of rior placement (Treatment period (na.ofmonthst—_[e)Date of prior placement) Reason for replacement (Monthly reatmentfee: (a) wasootcanal treatment performed? (@) Were teth extracted forthe appliance? (Toul fee =a (©) Date of extraction: (0 ncicate teeth replaced by this appliance: | HEREBY CERTIFY THATTHE ABOVE SERVICES AS INDICATED BY DATE HAVE BEEN COMPLETED TANF “SIGNATURE OF DENTIST i Pan-American Life Insurance Company of Trinidad and Tobago, Ltd, 91-58 vincent Sureet|Port of Spain, Republic of Tinidad &Tobago| Tet 868.625.4426 Fat: 868.623.4923|paligcom cuwo: os Page 2082