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    Claim Form of TPL Life

    Uploaded by

    Yasir Mushtaq
    This 2-page document is a medical expense claim form containing sections for claimant statement and physician statement. [SECTION 1] requires claimant to provide policy and patient details, illness history, expenses claimed with receipts. [SECTION 2] requires attending physician to provide hospital details, treatment period, medicines prescribed and declaration. The form collects necessary information to process a medical reimbursement claim and requires supporting documents like bills, reports and copies of ID.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Claim Form of TPL Life

    Uploaded by

    Yasir Mushtaq
    159 views2 pages
    This 2-page document is a medical expense claim form containing sections for claimant statement and physician statement. [SECTION 1] requires claimant to provide policy and patient details, illness history, expenses claimed with receipts. [SECTION 2] requires attending physician to provide hospital details, treatment period, medicines prescribed and declaration. The form collects necessary information to process a medical reimbursement claim and requires supporting documents like bills, reports and copies of ID.

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    This 2-page document is a medical expense claim form containing sections for claimant statement and physician statement. [SECTION 1] requires claimant to provide policy and patient details, illness history, expenses claimed with receipts. [SECTION 2] requires attending physician to provide hospital details, treatment period, medicines prescribed and declaration. The form collects necessary information to process a medical reimbursement claim and requires supporting documents like bills, reports and copies of ID.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    159 views2 pages

    Claim Form of TPL Life

    Uploaded by

    Yasir Mushtaq
    This 2-page document is a medical expense claim form containing sections for claimant statement and physician statement. [SECTION 1] requires claimant to provide policy and patient details, illness history, expenses claimed with receipts. [SECTION 2] requires attending physician to provide hospital details, treatment period, medicines prescribed and declaration. The form collects necessary information to process a medical reimbursement claim and requires supporting documents like bills, reports and copies of ID.

    Copyright:

    © All Rights Reserved
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    You are on page 1of 2

    MEDICAL EXPENSE - CLAIM FORM

    SECTION 1 : CLAIMANT STATEMENT


    (To be filled by the Claimant)

    POLICY PARTICULARS
    Name of Company :

    Name of Employee : Emp. ID :

    Name of Patient : CNIC # of Patient :

    Age of Patient : Wellness Card No. :


    Relationship with Employee : Policy No. :

    DETAILS OF ILLNESS Pre & Post Hospitalization OPD Hospitalization


    Date of illness first noticed : Date of recovery :

    Diagnosis :

    Has the claimant suffered from this illness before? Yes / No (If yes, please give date(s) and details below)

    TOTAL AMOUNT OF CLAIM Pre & Post Hospitalization OPD Hospitalization


    Please list in the column below all expenses claimed and attach original (not photocopies) of all relevant paid receipt supported by relevant
    prescriptions and discharge summary
    Relationship Amount (in
    Sr. No. Receipt No. Date Name of Expense Patient's Name
    with Employee PKR)

    Total

    Page 1 of 2
    DECLARATION BY THE INSURED PERSON & ASSURED
    I/We, as a claimant, hereby declare that the information provided in the form are true and complete to the best of my/our knowledge, belief, and
    record. I also hereby authorize TPL Life Insurance Limited in order to seek information from any doctor, hospital, laboratory, any other organization or
    person that has any record information or acknowledge of health/treatment and from any other Insurance / Takaful company to which a proposal has
    any time been made, and the giving of such information.

    Employee Signature Employer Signature with Stamp Date of Statement

    SECTION 2 : PHYSICIAN STATEMENT


    (To be filled by the Attending Physician - IN CASE OF HOSPITALIZATION)

    DETAILS OF HOSPITAL
    Name of Hospital attended :
    Name of medical practitioner consulted :
    Period of confinement : From : To :
    Were any medicines prescribed : Yes / No (If yes, please list the medicines prescribed and administered below)

    DECLARATION BY THE ATTENDING PHYSICIAN


    I confirm having treated Mr/Mrs/Miss: between the dates and and
    that the details shown on this form are consistent with my own knowledge of the patient.

    Signature of Attending Physician with stamp Date of Statement

    *Note:
    1) Mandatory documents which needs to be submitted with claim form are as follows:
    a) Proper itemized hospital original bills
    b) Discharge Card / Summary
    c) Support / Evidence (Reports, prescription etc.)
    d) Attach valid copy of CNIC and Wellness Card
    2) Form needs to be completed in all aspects

    TPL Life Insurance Limited (Formerly AsiaCare Health & Life Insurance Company Limited)
    33-C, Shahbaz Commercial Area Lane-4, Phase VI DHA, Karachi-75500
    Tel: +92 21 35171701-10 Email: [email protected]

    Page 2 of 2

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