ADNIC Claim

PART 1

COPY PART1 OF-

TF4SIOT.

Parr2 in ustbecompleted Patient’s ContactNo./Ntobile ToMandatory) by the doctor/specialist givirig detai1s of treatment received.

Submit this formwitori@na) account(s) with in 45 days of the expenditure being incurr€'d.

Your claim will not be consiJered if not subrT1itteH with in the above Per od. A NEW CLAIM FORM IS RE-QUIRED EACH TI/v\E YOU SUBMIT A CCOUNTS.

Patient’s Membership No.:

Voucher No.

Group Member’s Name(Mr./Mrs./Miss):

Employer’s Name:

Patient’s Name if not Group Member):

Patient’s date of brith:

Patient’s Contact No./NtobileT Mandatory:

If Patient is not the Group Member,tick relationship:

Wife

Husband

Child

For an in-patient stay in hospital please enter date(s)of admissionan discharg

AdmissionDate

DischargeDate

Is the cost of this treatment also covered by anyother insurers

Was the treatment necessary as the result of an accidents

If the answer to either question is YES, please give full details.

I here by claim for costs of treatment and declare that, to the best of my knowledge and belief, all information given in support of this claim is true and complete

Member’s Signature:

Date

PART 2

To be completed by Doctor/Specialist who carried out the treatment

Please complete this form in BLOCK CAPITALS

Condition requiring treatment

Details of treatment/operation/on set of illness

Name(s),qualifcation and address(es)/LicenseNo. of Doctor/Specialist/Provider LicenseNo.

ABU DHABI NATIONAL INSURANCE COMPANY