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07BF1426 2 Original PDF
07BF1426 2 Original PDF
rhe issue or this rorm does nor consritute an admission ;fi:ltHi"o1}L'n:,fffi:"J'X3'fSloor"u"o, *e paymenr wiil auromaricaily be credited to rhe
"rT:r*i
account from which your premiums are collecled, unless that account is a credit card account, in which case an altemalive account number should be provided.
lf payment is to be credited to an alternative a6ount, please provide the relevant details in pan 7 below
ueE
When did patienl become aware ol
-coli'
Has patient suffered from this condition before? io fed"oo
lf yes, give dates and details of trealment:
h hlqjdef
Should banking delails sfafed aboye differ from that of your debit order,
please submit a bank statement/cancelled cheque with your claim form.
I certiry that the banking details are coffect, failing which AIG Life South Africa Limited is absolved against all direct losses, liabilities, suits, proceedings, costs,
claims, demands, charges and expenses (including all legal and professional fees and disbursements) in respect thereof. I accept that it is my responsibility to
inform AIG Life South Africa Limited of any changes in my banking delails, failing which AIG Life South Africa Limiled will a€ept no liability for changes which are
not communiGted or communicated timeously.
I further declare that the information given is true and complete to the best of my knowledge and belief and authorise any hospital, physician or other person who
has attended to me to turnish to AIG Life South Africa Limited or its representatives any and all infollglion with respect to any sickness or injury, medical history,
consultations, prescriptions or treatment, and copies of all hospital records, including the results
be considered as efiective and as valid as the original
AIG Life SouthAfrica Limited isa Licensed Financial Seruices ProviderFSP No. 15804 Reg. No.2001/016602/06
LIFE PEGLERAE HOSPITAL(PTY) LTD
PR No 5808359
].73 BEYERS NAUDE DRIVE
LIFE PEGLERAE HOSPITAL (PTY) LTD RUSTENBURG, 0299
T/A PEGLERAE HOSPITAL P.O.BOX 244 RUSTENBURG O3OO
Reg . No .200L/ 0220e8 / 07
VISIT/
BTLLING CLERK)
ADMIT PT HATTINGH/ B R, DR Pr. No 460L629
REFER Pr KRUGER/ A 'J, DR Pr. No ]-4568]-4
CPT/ICD CODES
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P ICD N]-O
s rcD 896.6
s rcD 895.5
C ICD I1O
c rcD E78.5
c rcD 272.0
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R Fl.ages
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T]EKREKEIIIIIG Rekeni ngnomner l,:il 322 39, t
Standard Bank l November 20li
W 7 dae
Staattydperk ll
RUSTENBURG Rekeningbestuurder
ii,li::i60 101
BRANCH Te'l efoonnommer 341
Transaksi ebesonderhede
Transaks i ebeskrywi ng
U moet asseb'lief a1le transaksies op hierdie staat nagaan en die bank s0 gou as noontlik rran teenstrydighede in kennis ste'l