1107398b-09a0 - Salaam Health Claim Form

Claim Form
Important Instructions: (Please read carefully)
1. In order for us to provide fast and efficient services, kindly complete the form accurately in CAPITAL LETTERS.
Photocopies of this form can also be re-produced.
2. Completed forms should be sent within 30 days of the expense incurred date to: Health Division, Salaam Takaful Limited, Business
Centre, 6th Floor, Block 6, PECHS, Shahrah-e-Faisal, Karachi.
3. Please attach the following documents with the form:
a. Original itemized bill and original payment receipts, these should be issued on the official bill/receipt book of the
hospital/Pharmacy/laboratory.
Hospital Bill should mention type of accommodation/room and breakup of total bill as per below:
Room Charges per day Lab Tests/Radiology Charges Doctor visits fees Surgeon fees
Operation Theatre Charges Anesthesia Charges Medicines used during hospitalization Other miscellaneous expenses
Blood & oxygen charges
4. Laboratory, Radiology, Ultrasound reports along with Doctor Prescriptions for the same.
5. Itemized, dated, bills of the medicines purchased, supported by Consultant prescriptions specifying quantity and respective dosage.
6. Hospital Discharge summary / card (in case of hospitalization)
7. Copy of Birth certificate (in case of delivery / child birth)
8. Copy of death certificate, if any.
9. Copy of CNIC and Health Card
TO BE COMPLETED BY THE EMPLOYEE / PATIENT:
Name of Employer Policy Number
Name of Employee Health ID #
Name of Patient Total Amount Claimed (RS.)
Date of Birth Relationship with Employee
Diagnosis/treatment Duration of Illness/injury
Date of Admission Date of Discharge
Contact Number/Email CNIC Number
Is the patient entitled to any other benefit or compensation from any other source whatsoever? If so, name the company or the
association, or source, and give the amount of benefit payable by each:
DECLARATION BY THE EMPLOYEE / PATIENT:

I, hereby certify, that all answers, and all documents submitted with this form are complete and true to the best of my knowledge and
belief.
I, hereby, authorize any Doctor, Hospital, clinic, or medical provider, any insurance/Takaful company, or any company, institution, or any
other person who has any record or information about me and/or of my family members to provide Salaam Takaful Limited with the
information, including copies of their records with reference to any sickness or accident, any treatment, examination, advice, or
hospitalization. Any photocopy of this declaration/authorization shall be taken as the original copy.
__________________________ __________________________ ___________________

Signature of Patient / Employee Signature & Stamp of Employer Date
TO BE COMPLETED BY THE ATTENDING PHYSICIAN / HOSPITAL:
Patient Name:
Primary Diagnosis Secondary Diagnosis
When did the symptoms first appear? Day Month Year
When did the patient first consult for this complaint? Day Month Year
Has the patient ever suffered from/been treated for the same or related condition? If yes, please provide details with dates:
In case of Hospitalization:
Name/ Address of the Hospital:
Phone Number / E mail:
Hospital Admission Date: Discharge Date:
Emergency / Elective Treatment?
Details of Surgical, Gynecological or Obstetrical procedure performed, (if any):
Type of Anesthesia Used (Tick) (LOCAL / GENERAL)

Is further treatment anticipated? (Yes / No ) (If Yes, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _)
I, hereby certify that my answers to the foregoing questions are correct and true, to the best of my knowledge
and belief.
Signature / stamp of Attending Doctor

Name & Address
Phone Number & Email Address
Credentials/Qualifications
Date
For Salaam Takaful Ltd. Use Only

Policy Number Emp. Health ID
Claim Number Claim Entered By
Claim Received Date Cheque Number
Claim Approved Date Cheque Dispatch Date
SALAAM TAKAFUL LTD.
HEALTH INSURANCE DIVISION
BUSINESS CENTRE, 6TH FLOOR, BLOCK 6, PECHS, SHAHRAH-E-FAISAL,
KARACHI 75400. (021-111-875-111 / 0302-8228212 / 0303-8228466)

1107398b-09a0 - Salaam Health Claim Form

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1107398b-09a0 - Salaam Health Claim Form

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Claim Form

Important Instructions: (Please read carefully)

Blood & oxygen charges

Name of Employee Health ID #

Name of Patient Total Amount Claimed (RS.)

Date of Birth Relationship with Employee

Diagnosis/treatment Duration of Illness/injury

Date of Admission Date of Discharge

Contact Number/Email CNIC Number

DECLARATION BY THE EMPLOYEE / PATIENT:

__________________________ __________________________ ___________________

Primary Diagnosis Secondary Diagnosis

When did the symptoms first appear? Day Month Year

Name/ Address of the Hospital:

Phone Number / E mail:

Hospital Admission Date: Discharge Date:

Emergency / Elective Treatment?

Details of Surgical, Gynecological or Obstetrical procedure performed, (if any):

Type of Anesthesia Used (Tick) (LOCAL / GENERAL)

Signature / stamp of Attending Doctor

Phone Number & Email Address

For Salaam Takaful Ltd. Use Only

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