Déclaration en cas de maladie ou d’accident
A renvoyer à Allianz Belgium s a Assurance Hospitalisation Sinistre Santé – 10 C2ES Rue de Laeken 35 1000 Bruxelles Renseignements généraux Nom, prénom et numéro matricule de membre du personnel assuré : (nom de jeune fille pour les femmes mariées) Adresse : Rue : N°/Boîte : Code postal / Localité : Tél
Medical Questionnaire - Allianz Care
As the applicant, I sign this declaration and Medical Questionnaire for and on behalf of all persons included in this Medical Questionnaire Applicant’s signature Applicant’s printed name Date DDMMYY Allianz Worldwide Care SA, acting through its Irish Branch, is a limited company governed by the French Insurance Code
Mediclaim Insurance/UIN- BAJHLIP21536V022021/Page 2 of 21
Bajaj Allianz General Insurance Company Limited Mediclaim Insurance/UIN- BAJHLIP21536V022021/Page 3 of 21 2 19 Hospitalisation Hospitalization means admission in a Hospital for a minimum period of 24 consecutive ‘In-patient Care’ hours except for
ALLIANZ HOSPITAL INCOME PROTECT ALLIANZ ACCIDENT PROTECT
Claim for hospitalisation (Allianz Hospital Income Protect) 住院入息索償 (安聯住院入息保障) - Completed and duly signed Claim Form 已填妥之索償表格 - Copy of medical receipt(s)/ bill with diagnosis 附有臨床診斷之醫療收費單據副本 - Copy of discharge slip/ summary 出院紙 / 出院撮要副本
Claim Form May2019 - Bajaj Allianz General Insurance
vii Pre-Hospitalisation period: days viii Post Hospitalisation period: days b) Claim for Domiciliary Hospitalisation: Yes No (If yes, provide details in annexure) c) Details of Lump sum / cash benefit claimed: i Hospital Daily Cash Rs ii Surgical Cash Rs iii Critical illness Benefit Rs iv
Travel Insurance Claim Form
Please contact Allianz Global Assistance on 0800 630 117 for access including the Declaration on page 7 Dental and/or Hospitalisation Claim
Mediclaim Insurance Policy Wordings - IRDAI
1 In-Patient Hospitalisation expenses: In the event of any claim/s becoming admissible under this policy, below expenses are paid subject to policy terms and conditions a Room, Boarding Expenses provided by the hospital / nursing home b Nursing Expenses c Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialists Fees d
Bajaj Allianz General Insurance Company Limited Regd & Head
I also consent & authorize Bajaj Allianz General Insurance Company Limited, to seek necessary medical information / documents from any hospital / Medical Practitioner who ha s attended on the person against whom this claim is made
SURGICAL AND HOSPITALISATION EXPENSES CLAIM FORM
SURGICAL AND HOSPITALISATION EXPENSES CLAIM FORM It is important that a complete answer be given to every question If insufficient space is provided for your answers please continue on a separate sheet When you see Yes/No please tick appropriate box INSURED OR POLICY HOLDER 1
CLAIM FORM PART A - Apollo Munich Health Insurance
SECTION H - DECLARATION BY THE INSURED Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign PART B (TO BE FILLED IN BY THE HOSPITAL IN CASE OF CASHLESS CLAIMS) The issue of this Form is not to be taken as an admission of liability Please include the original preauthorisation request form in lieu of PART A
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