aN Ma RO aL NieLva lels dies ca ceie keane S poset Section A-To be filled in by the Claimant/Patient 1, Name of he Company / Policy Holder nea EA 2. Nome of the Claimant : [Soe the & covet one which chau as abe prepared in cove of ember, He berry ion ames a Cael re) 4, Full Address of Claimant ie OO 5, Full Name ofthe Patient ed 6 Dae ofthc tet a a 8. Policy Number Co ticle] Phone Number: 9. Poon’ Relofonship to Claimant] Employee] Dependent ‘Tol Amount Claimed in Rx: [— 10. State the nature of = ness /njry/Medical Condition - oe 11. State the date ot which eympms fis! cou a 12 The Patient last working doy 13, Nome he hospital fom where thateatnan! 7 has been taken for present coriion 14, Addiess of he hospital 15. Nome of he Doctor 16, lf we requie an independant medical examination at which addtes the patint would be loco: | 17. 1s the patent ened for any lhe insurance or medical benef if yes, please provide bie deals: 18. Ishi canfnuation of previous or curen eatment? If yes please give bist deta: \ i iy that ll ons documents submited wth the form are complete and at of my ks provide bile life Instance Signature of the pationt Signoture & Stomp of the Employer Date (de/men/yvy) Li the potent is under 18 fino the claimant should sign Location of Branch Bank Account nubor ARQ.Section B-To be filled in by the treating Doctor 1 None the a OO) 2. Howlong youhave been patents dogo? [SY 3, Since how long he paten' is fling rom fhe present mediclcondton? Phase soe he enc! dato & year [Sd 4. What is your diagnoses regarding injuy/tlnass/medical condition? 5. lease provide biel detail of sigical, Gynaecological or Obsitical procedure pedoxmed (if any) 6. Please tck he appropri regarding te disease Cleoncewta Enwerurr CJesucuamacuness [CJeoswnc [Jsucoe [Jeonmesnne [Jomers 7, Meese provide bt detail reatnon given oF prescbed 8. Hos the poten! ever sled from or been Heated for he same or related medical condition? If yes ploose brief details wih dates 9. Incase of Matemiy aim ploase stale expected date of delivery: | ~SY 10, caso of Casaion Section, please spocty is medical necessty [Td 11. The date you were fis conse for his condition CO | hereby cently that my answers 1o he above questions are contact and 4uo to the bos of my knowledge and bell Name ofthe Doc: _[ Adehos ct ibe Doce [ Phone Number: OO - NOTE: Proving coved wlometon's he responsibly cf cansilon & poten bo, in case a mate ierence is four ir ipation! Clin Form ond Final Dicharge ‘Smeny, hen he payer ol hoyptoiaoson sxpene woul be he expen of censan & patients J Bate: ) Patient's Signature EMERGENCY CASES: In evr lan Emergency he Potent could nh any heap wher spat or ref poral fbb lif ssorce Company lied cose of TNONSPN Hoypta, he chages nce by fo sro wil be eink proved ha he el expaiee als wth he i powded to hin“hor_ A Orgel Documents thle io hospaaten Iosptol Bl, Dachogge Summary ee) cleng wih cul led inion Clam Form shod be sro biee fe hauonce Camry Lined fr reirbaseren Fhe woatnen i ovaled fom NONEPN Hospital, the charges incured bythe nated willbe reimbursed, previ thal he el expenses ols wh, tho line provided histor Al Orginal Docierts yelled to hespaalaton (Hosiel Bd, choge Summary ee) alg wih dyed Inatort Cam Fox shoul bo sort bee lle Iraronce Corpany lined fer inbureert NON-EMERGENCY CASES: Wie going or NONEMERGENY Teoimet os Plaraed Surgais ot Hespiizaton whare Heatnet so eal fo Forel Hosp he insured host ke prior apc er si ie lsc Compony linied by Hing PART A ef he Clam Fm on making PAR 8 filed by to oat doc. The Cam ‘Com along wih sappatie Jocuments for hspicton shoud be send o Conpony for approval. Th ied willbe sued CREDIT LETER vai fx 30 DAYS nfvor oh Cancer Hosp hich cll be ube by nud othe hoepl Al lor Hosptaaaton wil be sled dec by jb Ue Inazonce Company Um No exh foyer wok be requed by Palert excep tenadca me os water bates, onpers PLEASE NOTE: Incmpnie Clo Fos would rt be accepted or proceang of payne. Allerighel decir shoud be ofocked wh the cms. hotocpies eno ecopible Following Jubilee Life Ineuronce Company Limited Ofces wil be avilable on working days to ests! you KARACHI (HEAD OFFICE) LAHORE: ISLAMABAD: 74/1 (AAR, M0 KHAN BAC, 214, CUBE, ODED, FST HOOR MINKAS RAZA, 20 SKN 4895, MAN FERO2 UR ROHD, SHANSABAD, MAN KUIEE ROAD, ABACHS74000,PARSTAN acre BAWAIFINDL 1H. 0219501107175, eodzaseq201219 ‘a 051-457520852105218 Fax 0219561134, 35810959 nw onaasaaiors Fax 0514575200 Jubilee Life Insurance Company Limited (foray New Jubiae Lie Insurance Compony limited 74/ 1A. lalozor, MT. Khan Road, Karachi - 74000, Poison, Phone: 021] 35611071 - 5, 3561 1802-8, Fax: (021) 35610959, 35610805, SMS: JU 1313 UAN: 111-111-554 UU, Emel: infodjublalif.com, Website: ww ubleaie.com