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C3 eME f i;

FORTUNE GENERAL INSURANCE CORPORATION

CLAIM REPORT
ACCIDENT & HEALTH INSURANCE

NOTICE TO INSURED/ OAIMANTS

1. Accomplish Part A of this form by answering all question accurately and completely, placing "N.A." where not applicable and by checking
that appropriate boxes.
2. Request your attending physician to accomplish Part B of this f o r m , " Attending Physician's Statement"
3. Attach original or copy of documents cited hereunder. You will be notified in case additional documents are needed.
4. Forward this form with the pertinent documents t o any office of Fortune General Insurance Corp. near your vicinity.
5.

REQUIREMENTS
A. ACaOENT MEDICAL REIMBURSMENT* DEATH CLAIM ACCIDENTAL DEATH & DISABLEMENT &
• Fill up completely the CLAIM FORM UNPROVEKED MURDER & ASSULT**
• INCIDENT REPORT/ POLICE REPORT • Fill up completely the CLAIM FORM
• AFFIDAVIT OF THE CLAIMANT • POLICE REPORT/ AFFIDAVIT OF THE CLAIMANT
• MEDICAL BILLS & RECEIPT • DEATH CERTIFICATE/ NOTED with REGISTRY NU MBER
• Physician's Prescription (RX) • O.R of BURIAL/FUNERAL
• ID or Certificate of School/ Company • PICTURE OF DAETH (during funeral)
D. ILLNESS/ NATURAL DEATH C U I M * »
B. DAILY HOSPITAL CONFINEMENT (lUNESS)* • Fill up completely the CLAIM FORM
• Fill up completely the CLAIM FORM • DEATH CERTIFICATE/ NOTED with REGISTRY NUMBER
• HOSPITAL BILL • O.R of BURIAL/FUNERAL
• DISCHARGE SUMMARY/ MEDICAL CERT. • PICTURE OF DEATH (during funeral)
• ID or CERTIFICATE OF SCHOOL/ COMPANY
*• NOTED IF ADMITTED:
'ADDITIONAL REQUmMeNTS FOR CLAIMANT • HOSPITAL BILL
• BITH CERTIFICATE (insured) • DISCHARGE SUMMARY/ MEDICAL CERTIFICATE
• VALID ID (claimant) ADDITIONAL REQUIREMENTS FOR CLAIMANT
• BIRTH CERTIFICATE (insured)
• ID or CERTIFICATION OF SCHOOL/ COMPANY
• MARRIAGE CONTRACT (parent)
• VAUD ID (claimant

PART A - TO BE F I L L E D UP BY INSURED OR BENEFICIARY

Name of Group, If group policy Policy No.

Full name of Insured Full name of Claimant (other than insured)

Address Birthday of Claimant

Relationship of Claimant to insured Occupation

a. Date insured or date of illness: Month Day Year

b. If injured, describe in detail where and how the accident happened.

c. If due t o illness, describe nature..

If due to illness, have you received medical treatment YES NO

Or advice before this condition? If yes, please give detail.
Hospital; Physician: Date:

Indicate name and address of attending physician or surgeon:

Name: Address:

If hospitalized
Name: Address:

^>eriod of hospital confinement; FROM: TO: