CLAIM INTIMATION FORM

GROUP LIFE & HEALTH INSURANCE DEPARTMENT

Protective Islami Life Insurance Ltd.
Tel: 88-02-9840616-7, Fax: 88-02-9840618

FROM:  
SUBJECT:  
Name of Employee:  
Designation:  
Branch/Div./Dept:  
Name of Patient:  
Relationship of Employee (if the patient is a spouse/dependent):  
Date of Admission:  
  Membership No:*
Name of Hospital:  
Address:  
Telephone No.  
Name of Doctor:  
Nature of Illness:  
Treatment Advised:  
Expected Date of Discharge:  
Signature of Employee   Signature size Maximum 30kb
Signature of Plan Secretary   Signature size Maximum 30kb
Copy to:
N.B.: Please send this information directly to Protective Islami Life Insurance Ltd. by FAX before or at the time of admission to a hospital/clinic and mail original copy to Head Office-HRD- ........ for necessary action.

   

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