Claim Form

Policy No.# 7085 /2017

1 Name of the Organization BRAC , Bangladesh

2 Name of Employee:
3 PIN : E-mail Mobile no

4 Name of Patient:
5 Relationship with Employee Self Spouse Child
6 Claim Type Life Health Others
7 Policyholder's ID No.: 7085……………… bkash no
Name and Address of
8
Doctor/Hospital/Clinic:

9 Date of Admission: Date of Discharge:

Please collect database or software Original bill details, Itemized or break down bill from hospital where available in case reimbursement.
Otherwise we have to collect it and claim settlement time will be longer. Please avoid Overwriting or writing by self or any other way of change
10
the bill. Submit your claim within allowable time limit-within 4 weeks from date of discharge. Photocopy money receipt or self written money
receipt will be out of consideration.
11 Breakup of Expenses:- Amount (Taka)
12 Hospital Accommodation:
13 Consultant’s Fee:
14 Routine Investigations:
15 Medicines & Drugs:
16 Surgical Charges:
17 Ancillary Services:
18 Other Expenses (if any) i.e ambulance:
19 Discount (if any):
20 Total Claim Amount:

21 Signature with Date & Seal

Employee Supervisor Verified by HRD
22 Accounts Details A/C No Bank Name:
Routing Number: Branch Name:
Thana : Districts:
Ask your Bank. If your Bank has no ability to receive EFT, change your A/C no that has ability to receive EFT. You are cordially requested to
On line facilities: enclose a copy of 1st page of your cheque book or account statement with claim documents to ensure correct account info.
23 2nd Contact Number: Supervisor Spouse
24 Check List: ◘ Hospitalization Advice prescription ◘ Original summery bills and breakdown Bills/Receipt (Database) for total claim amount
◘ Original requisition slip for all medical & surgical items ◘ Copy of Discharge Card/ certificate ◘ Copy of Investigation reports ◘ A/C info
◘ Copy of Cheque Book ◘ Verified with Bank for EFT ◘ All contact number with e-mail ◘ All info duly filled and rechecked
Note: If any payment misplaced due to your provided wrong information, Company shall have no liability for such misplaced payment.
25 For Claim Dept of Guardian Life Insurance Limited
Received Date: Settled Date: Settled Amount: