Scribd Logo
Upload

Welcome to Scribd!

  • 107 views

    V ' Exgv 'Vex DG©: Health Insurance Claim Form

    Uploaded by

    jakaria emtiaj
    This document is a health insurance claim form from Guardian Life Insurance Limited in Bangladesh. The form collects information about the claimant, patient, hospitalization details, treatment expenses, and requires supporting documents like bills and reports to process an insurance claim.

    Copyright:

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

    V ' Exgv 'Vex DG©: Health Insurance Claim Form

    Uploaded by

    jakaria emtiaj
    107 views2 pages
    This document is a health insurance claim form from Guardian Life Insurance Limited in Bangladesh. The form collects information about the claimant, patient, hospitalization details, treatment expenses, and requires supporting documents like bills and reports to process an insurance claim.

    Original Description:

    Health insurance claim form

    Original Title

    Health-Insurance-Claim-Form

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document is a health insurance claim form from Guardian Life Insurance Limited in Bangladesh. The form collects information about the claimant, patient, hospitalization details, treatment expenses, and requires supporting documents like bills and reports to process an insurance claim.

    Copyright:

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

    V ' Exgv 'Vex DG©: Health Insurance Claim Form

    Uploaded by

    jakaria emtiaj
    This document is a health insurance claim form from Guardian Life Insurance Limited in Bangladesh. The form collects information about the claimant, patient, hospitalization details, treatment expenses, and requires supporting documents like bills and reports to process an insurance claim.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    CD FORM NO - 01

    MvwW©qvb jvBd BÝy¨‡iÝ wjwg‡UW


    cÖavb Kvh©vjqt cywjk cøvRv KbKW© (†j‡fj-13) UvIqvi 2, cøU-02
    †ivW-144, ¸jkvb-1, XvKv-1212, ‡dvb: +88 09 612016622

    ¯^v¯’¨ exgv `vex dg© Head Office: Police Plaza Concord (Level-13), Tower- 02
    Plot # 02, Road # 144, Gulshan-1, Dhaka -1212.
    HEALTH INSURANCE CLAIM FORM Phone: +8809612016622, Web: www.guardianlife.com.bd

    exgv `vexi aiY t ewnwe©fvM mvavib Pÿz `šÍ fwZ©Kvjxb nvmcvZv‡j fwZ© cÖm~wZ
    Claim Type: Outpatient General Optical Dental In-patient Hospitalization Maternity
    ÷vd AvBwW/wcb cÖwZôv‡bi bvg
    Staff ID/ PIN Organization’s Name
    cwjwm/m`m¨ b¤^i exgvKvixi ‡gvevBj b¤^i
    Policy No. / Member ID Policyholder’s Mobile No.
    exgvKvixi bvg weKí †gvevBj b¤^i
    Policyholder’s Name Alternate Mobile No
    ‡ivMxi bvg exgvKvixi B‡gBj
    Name of Patient Policyholder’s E - mail
    exgvKvixi mv‡_ m¤úK© wbR ¯^vgx ¯¿x cyÎ Kb¨v wcZv gvZv
    Relation with Policyholder Self Husband Wife Son Daughter Father Mother
    nvmcvZvj/wK¬wb‡Ki bvg GjvKv
    Name of Hospital/Clinic Area
    fwZ©i ZvwiL nvmcvZvj Z¨v‡Mi ZvwiL
    Date of Admission Date of Discharge
    wPwKrmv Li‡Pi we¯ÍvwiZ weeiY (Breakup of Treatment Expenses) UvKvi cwigvY / Amounts (Taka)
    ‡Kweb/wmU/weQvbv fvov(Hospital Accommodation Charge)
    Wv³vi wd:/ Consultation fee
    cixÿv-wbixÿvi LiP/ Medical Investigation Expense
    JlacÎ /Medicines
    Acv‡ik‡bi LiP /Surgical Expense:
    Avbylvw½K wPwKrmv LiP /Ancillary Services fee
    Ab¨vb¨ LiP (hw` _v‡K) /Other Expenses (if any)
    wWmKvD›U / Discount
    ‡gvU `vexi cwigvY / Total Claim Amount
    exgvKvixi weKvk bv¤^vi ( cÖ‡hvR¨ †ÿ‡Î)/
    bKash Number of Policyholder (In applicable case only)
    exgvKvixi e¨vsK wnmve msµvšÍ Z_¨ /Policyholder’s Bank accounts related Information e¨vs‡Ki kvLv I GjvKvi bvg Aek¨B D‡jøL Ki‡Z n‡e|
    ( BGdwU / EFT ‡c‡g›U MÖn‡b mÿg e¨vsK n‡Z n‡e) m¤¢e n‡j †PK eB‡qi Dc‡ii cvZvi d‡UvKwc mshy³ Kiæb
    e¨vsK wnmv‡ei bvg e¨vs‡Ki bvg I kvLv
    Account Name Bank Name & Branch

    e¨vsK wnmve b¤^i ivDwUs b¤^i


    Account Number Routing Number
    ÿgZvc©Y / Authorization: I hereby certify that the foregoing statements are full and true to the best of my knowledge and I
    hereby authorize all attached documents to be provided to Guardian Life Insurance Limited. Any copy of this authorization shall be
    taken as original. Avwg GZØviv cÖZ¨qb KiwQ †h, Dc‡iv³ wee„wZ mg~n Avgvi m‡e©v”P Ávbg‡Z c~Y©v½ I mZ¨ Ges GZØviv mKj mshy³ bw_c‡Îi
    Abywjwc MvwW©qvb jvBd BÝy¨‡iÝ wjwg‡UW †K mieivn Kivi ÿgZv cÖ`vb KiwQ| GB ÿgZvc©‡Yi †h †Kvb Abywjwc g~j `wjj e‡j MY¨ n‡e|
    ¯^vÿi/ Signature
    1*
    1*

    `vexKvixi ¯^vÿi I ZvwiL mycvifvBRvi / wefvMxq cÖav‡bi ¯^vÿi I ZvwiL `vwqZ¡ cÖvß Kg©KZ©vi ¯^vÿi I mxj
    Signature of the Employee/claimant with date & Seal Signature of the Dept./Div. Head with date & Seal Signature of the Authorized Person with date & Seal

    GKK exgvi ‡ÿ‡Î ïaygvÎ 1* cÖ‡hvR¨| wet `ªt MvwW©qvb jvBd cÖ‡qvRb Abyhvqx `vex mswkøó †h †Kvb bw_cÎ Z`šÍ I Zje Kivi AwaKvi msiÿb K‡i|
    Only 1* is applicable for Individual insurance . N.B.: Guardian Life reserved rights to verify or ask any documents relevant with the claims.
    mwVKfv‡e c~iYK…Z GB d‡g©i mv‡_ wb¤œwjwLZ KvMRcÎ mshy³ Kiæb
    Please attach following documents along with duly filled out this claim Form

    1. nvmcvZv‡j fwZ©i civgk© `vZv wPwKrm‡Ki †cÖmwµck‡bi Abywjwc


    Copy of Prescriptions of respective physician containing Hospitalization advice

    2. ‡gvU `vexK…Z we‡ji mswkøó mKj (weQvbv fvov, JlacÎ, wPwKrmK wd, cixÿv-wbixÿv, A¯¿cPvi BZ¨vw`) Li‡Pi we¯ÍvwiZ cwigvY
    D‡jøLmn g~j iwk`| WvUv‡em A_ev mdUIqvi †Rbv‡i‡UW wej fvDPvi AwaK MÖnY‡hvM¨|
    Original and itemized Bills / Receipts of all relevant expenses i.e. hospital accommodation, medicines, consultation fees, investigations,
    procedures, surgery, any medical or surgical items along with their requisition slips. Database bills are preferred.

    3. nvmcvZv‡ji Qvoc‡Îi Abywjwcmn mKj cixÿv-wbixÿvi wi‡cv‡U©i Abywjwc|


    Copies of discharge certificate, all investigation reports and others treatment records.

    4.e¨q cybtfi‡bi Rb¨ AbyMÖn K‡i WvUv‡em ev mdUIq¨vi cÖ`Ë we¯ÍvwiZ we‡ji g~j Kwc †cÖiY Ki‡Z n‡e| Ab¨_vq, exgv ‡Kv¤úvbx‡KB nvmcvZvj
    †_‡K we¯ÍvwiZ wej msMÖn Ki‡Z n‡e hv `vex wb®úwËi mgq `xN©vwqZ Ki‡Z cv‡i| AbyMÖn K‡i wej cwieZ©‡bi D‡Ï‡k¨ wb‡R ev Ab¨ Kv‡iv gva¨‡g
    we‡ji Kwc‡Z †h‡Kvb cÖKvi wjLv ev Nlv-gvRv Kiv †_‡K weiZ _vKzb| nvmcvZvj Z¨v‡Mi ZvwiL †_‡K Aby‡gvw`Z mgqmxgv Gi g‡a¨ exgv `vex
    Rgv w`b| ¯^-n‡¯Í wjwLZ ev d‡UvKwc wej we‡ewPZ n‡e bv|
    Please collect database or software generated original bill details and itemized or break down bill from hospital where available for
    reimbursement. Otherwise, Insurance company will collect it and claim settlement time will be longer. Please avoid overwriting or
    writing by self or scratching the bill. Submit your claim within allowable time limit from date of discharge. Photocopy of money receipt
    or self-written money receipt will be out of consideration.

    5. MvwW©qvb jvBd cÖ‡qvRb Abyhvqx `vex mswkøó †h †Kvb bw_cÎ Z`šÍ I Zje Kivi AwaKvi msiÿY K‡i|
    Guardian Life reserves rights to verify or ask any documents relevant with the claims.

    You might also like