PakQatarFamilyTakafulLimited
HeadOffice:SuiteNo.203205,BusinessArcade,P.E.C.H.S.,Block6,
MainShareaFaisal,Karachi,Pakistan
TelNo.(9221)438035761.FaxNo.:(9221)4386451
HospitalizationReimbursementClaimForm
;
;
Part
TobecompletedbythecoveredIndividualMemberonly.
Donotleaveanyblank,unansweredquestions,datesorsignatures,whereverapplicable.
TypeofClaim:
Prehospitalizationexpenses
Hospitalizationexpenses
PostHospitalizationexpenses
Prenatalexpenses
Deliveryexpenses
Postnatalexpenses
ClaimantName:
Participant(Employer)Name:
SchemeNumber:
SchemeStartDate:
SchemeEnd Date:
PatientsName:
PatientsTakafulCertificateNumber:
DateofBirth:
Patients Sex:
Male
Female
CNIC Number:
ResidenceAddress:
Residence:
Office:
Mobile:
1. Statethenaturemedicalcondition,injury,illness:
2. Onwhatdatedidthesymptomsfirst occur:
3. NameandaddressofPhysicianproviderfirst
consultedduetoabovementionedmedicalcondition:
4. Hasthepatientconsultedanydoctorfortheabovementionedmedicalcondition?
IfYes,foreachdoctorandhospitalconsulted,statenameandaddress,treatmentprovided.
NameofDoctor/Hospital
DateofConsultation
ReasonforConsultation
5. Doesthisclaimisrelatedtoanaccident?
Yes
No
Treatment/Results
YesNoIfYes,whatisthedateoftheaccident?
Givebriefdetailofwhereandhowaccidenthappened?
6. Givedetailsofanyotherhealth,medicalortraveltakaful /
insurance,workmanscompensation,socialsecurityorother
medicalbenefitstowhichthepatientmaybeentitled:
NameofHospital,wheretreatmentavailed:
DateofAdmission:
DateofDischarge:
TotalNos.ofdays
TotalamountofClaim(InPakRupees):
DECLARATION&AUTHORIZATION
I hereby certify that all answers to questions appearing on this form and documents submitted with this form are true and complete to the best of my
knowledgeandbelief.
I,theaboveclaimant,herebyauthorizeanydoctor,hospital,,clinic,ormedicalserviceprovider,takaful/insurancecompany,oranyotherinstitution,orany
person, who has any information or record about me and/or any of my dependents to provide PakQatar Family Takaful Limited with the complete
informationincludingcopiesoftheirrecordswithreferencetoanysickness,accident,disability,anytreatment,examination,medicalinvestigation,adviceof
healthcareprovider,.Photocopyofthisauthorizationshallbevalidastheoriginal.
DateofStatement:
SignatureofclaimantIndividualMember
Employeewillcompleteandsignthisformonbehalfofminorchildren
VerificationbyParticipant/Employer
I/Weherebycertifythatallanswerstoquestionsappearingonthisformaretrueandcompletetothebestofmy/ourknowledgeandbelief.Weunderstand
andagreethattheabovestatementshallformthebasisforTakafulcoverage.
DateofStatement:
SignatureofParticipant
