Claim form for in patient treatment

CLAIM FORM FOR IN PATIENT TREATMENT

Name

policyholder of policy No.

Policy No.

wish to submit a claim for reimbursement of expenses related to the illness/ injury prescribed in the informative form for inpatient treatment.

Name & Surname:

D.O.B

Address:

Telephones:

ID Number:

Email:

Details for the illness/ injury :

Hospital:

Doctor: