ADAMJEE LIFE ASSURANCE Page 1 of 2

Claim Form B: Physician Statement

Adamjee Life Assurance Co. Ltd
3rd Floor, Adamjee House,
‫ڈا���ن‬-(‫د�ى�رم)ب‬
ٰ
I.I. Chundrigar Road, Karachi - 74000 PAKISTAN

Deceased Information ‫������ت‬/‫��م‬

‫�����م‬/‫ ��م‬/ Deceased Name: _______________________ ‫ �پ�����م‬/ Father/Husband’s Name: ___________________________

� ‫ �� �رڈ‬/ CNIC Number: _________________________________ � � ‫ ��م‬/ Address of deceased: ______________________________
___________________________________________________________________________ �‫ �ر��ا‬/ Date of birth:_______________
Were you the regular family physician of the deceased? ‫����ر��ڈا��؟‬/‫�آپ��م‬
________________________________________________________________________________________________________________

For how long had you been treating the life assured? ‫����آپ�دار��ج�ر��؟‬
________________________________________________________________________________________________________________

Was the life assured your relative / family member?

‫��دارآ����د�ر�دار�؟‬
________________________________________________________________________________________________________________

Event Details ‫ا�ل�و���ت‬

‫ �ر�و�ت‬/ Date of death:_______________ �‫ و�ت � و‬/ Time of death: ( : ) AM / PM � � ‫ و�ت‬/ Place of death:_______________
� � ‫�ت‬/ Type of death: �‫ �ر‬/ Natural ��‫ �د‬/ Accidental �‫ا�لاور�د��در�ن�و‬/ Interval between onset and death: ( ) /Days
�‫ �ل��م)ا�و�ںا�ل(�ا‬/ Name of Hospital (If died in hospital): _________________________________________________________

Cause of Death: �‫�ت � و‬

Primary Cause: : �‫�دىو‬

Secondary Cause: : �‫��ى و‬

Any other disease / illness deceased was suffering from but

not potentially life threating �‫����اور�رى����ا�و��ا�ل��ا‬/‫��م‬

Past Medical History ‫����ر�رڈ‬

����‫��دہ�رى‬/ First Complaint about current illness: �‫ �ر‬/ Date:_______________
��‫��دہ�رى�دو�ى‬/ Second Complaint about current illness: �‫ �ر‬/ Date:_______________
Prior to current illness, was the deceased in regular Yes ‫�ں‬ No� ‫���آپ���������ج�وار��؟‬/‫���م‬،��‫��دہ�رى‬
consulation with you?

If yes, please provide details: : �������‫ا�ا‬

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Did you you refer the deceased to any other physician or hospital ‫�آپ����ج���دو�ےڈا���ل‬ Yes ‫�ں‬ No�
for any treatment ���‫��ج�وا‬
If yes, please provide details: : �������‫ا�ا‬

Sr. No Name of Physician Complaint About Treatment Duration Contact No. Correspondence Address
‫��ر‬ ‫ڈا���م‬ �‫���و‬ ‫�ج��ت‬ � �‫را‬ ����‫�و‬

1
2
3

If Accidental Death / Suicide ���‫ا��د���ت��د‬

�‫ �ر��د‬/ Date of accident:_______________ �‫�د� � و‬/ Time of accident: ( : ) AM / PM �������‫ �د‬/ Describe event in detail

��‫ا�ار‬

��‫ �ت‬/Investigation held? Yes ‫�ں‬ No� (If yes, please attach findings) (���������‫��ا‬،‫)ا��ں‬
�‫ ���ر�ا�مد‬/Autopsy Performed? Yes ‫�ں‬ No� (If yes, please attach findings) (���������‫��ا‬،‫)ا��ں‬

Declaration �� ‫ا�ار‬

I___________________________________________ medical attendant of the life insured _______________________________________

do hereby declare that to the best of my knowledge and belief the information given herein are true and complete.

. ��‫���ں��ر����م��ت�اوردر‬/�����‫�____________________________________����ڈا�اس�ت‬

I do hereby, authorize Adamjee Life Assurance Company Limited to extract my verisys from NADRA for my Life Assurance policy.
‫�آد���ا�ر����ا�رد��ں�وہ�ى�����درا�و���ل��۔‬

Signature & Duly Stamp with date

����‫د�اور��ر‬

Adamjee Life Assurance . 3rd floor, Adamjee House, I.I Chundrigar Road, Karachi Pakistan
Tel: (92-21)111-11-5433(LIFE) (Ext: 114) Claims Department: (92-346)8209366, Email: help_claims@adamjeelife.com, Web: www.adamjeelife.com