Wl MetLife American Life Insurance Company ll MHWTWIN MetLife Building, 18-20 Matihee! CA, "meTeLoLotE P.O. Box 9, Daka-1000, Bangladesh Tel : (880-2) 9561791 Group Medical Claim Form Fax: (880-2) a7ni2i (ea or woru.metife.com.bd pete Dalcyheere Nene ete [Groupee None BOL sure Oe 1O Number olalola}ola pa Diaby ant 1. Choimant's ame: 2 2.Cisimants Ose of ith Patents Name 4 Peet's of Bhs 5 Fabents Rltn wih mane 6 Nurs of icknesMecdent "Tol Amount Chena ‘Authorization, ray erty that lanier anal docarent uit wt the Cin Form ae complet an te. ere author any dco, spl cine armas provide, ryinsrance conan o anyother company, tution 2 Boy cher ars who has any record infomation about me anal® any cf my fry maroon vise Yee (American Lie nsurarce Company) withthe complete information, ncn css f tha reco wth reference oan skress a acide, ny teste, ‘examination, ave a eitaaton Ary photospy a th authorization sal be taken athe arial copy lsimants Name: /Onmants Dae Moco, _ emi. Employers Section | owl eguted dna chakad and atch? Yer ote 2.Choaia Payment mae inthe name of © Employee Employer (Provide request V 1 Assigned Provider (Provide request eter) Etployers Autores Pro's Sgntre Ses Dae Claim Submission Instructions + lease sbi separate lain forms fren sued ond orate anette Out satin /n-atint /Matenty/ Dent / Opt! Ply Ye + Suomi al cess esis documents win 30 (hit Day rom theincure date F ‘Piease attach following documents with this Claim Form (Out Patint Treatment + Origine money eet showing te ated physicians detaled charges slang wih stamp and sinstre + Grin! tees parnay showing the dat of purchase, tame pain, quant ana name of dupe long with otocop of physician's prescrton. + Origa ein snowing vargas fr each the Laborato tes rd ther anamnatone do ‘tami’ ar pratoopies othe este f examinatoneurderaken supported by th esectivephysians rues to underae In-Patiane Treatment ‘tensed ag! hespt bil arid byte ofl ace forthe etal amount pa + ona reso hovig etaningPhyscins/Sugtons has elong wh i stars and sia, + Photacopy of detale hep schrge rept. For Cita lines or Dealt Beat, Age Prat must be submitas ny ofthe following documents i aecepted a Age Poot ‘ pnotacopy of Nations 10 Card * Photocopy of Passport 1 Photocopy of Diving License not0capy of Carat of S.C or aeulvalent examinations NA Comany maya fr atonal infowaton ae documents, eames nacestary. "1 Paleyelder Th Inttiton which purchases rons the pay cha 2.Casinart Banetciary. The person arstynho's named a ec the nurancoPoiey Ben Aran Lite nuance Camry iincrpoted inthe USK omited Cambaey