South Asia Pakistan Terminal Ltd

Medical Reimbursement Claim Form

Employee Name: ________________________________ Emp ID: ______________

CNIC: __________________________________________ Cert ID: _______________

Date: ______________

Outpatient Services (OPD) Pre & Post Natal (Maternity)

Email: ______________________________ Contact No: ____________________

Note: Attach all original bills with doctor’s (Prescription, Reports, Referrals, Summary)

S.No Expense Description Employee Spouse Children

1 Consultation Fee

2 Medicines

3 Diagnostic Tests

4 Dental Treatment

5 Preventive Vaccination

6 Optical Treatment

7 Others

Total

Total Amount: __________________________________

AUTHORIZATION
I, the above claimant, hereby authorize any doctor, hospital or any other person who has any record or
information about me and / or any of my family members to provide with the complete information, including
copies of their records with reference to any sickness or accident or any treatment.

Doctor’s Name: _________________________________ Doctor’s Location: ________________

Employee Signature: _____________________________ HR Rep: ________________________

Allianz EFU Health Insurance Limited

37-K, Block 6 PECHS, Karachi, 75400 Pakistan.
Phone (021)111-432-584 (EXT 211/410/412),0300-8208555
Email: customer.relations@allianz-efu.com