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