UBL INSURERS LIMITED

OUT-PATIENT CLAIM REIMBURSEMENT FORM

EMPLOYEE INFORMATION
Employee ID : C3743 AL #
Employee's Name : M. Abdul Wajid Rai Cell # 03458561408
Email ID abdul.wajid1@telenor.com.pk Date ( month): August, 2016
OPD CLAIM REIMBURSEMENT DETAILS

CASH
CHECK THE NATURE OF EXPENSES AMOUNT
SR. MEMO/ DATE PATIENT`S NAME RELATIONSHIP
CLAIMED
Receipt# MEDICINES CONSULTANCY TESTS OPTICAL DENTAL
1 147 02-08-16 1000 M. Abdul Wajid Self 1000
2 149 05-08-16 1000 M. Abdul Wajid Self 1000
3 5669 05-08-16 322 M. Abdul Wajid Self 322

4
5
6
7

8
9
10
TOTAL (in words) Two Thousand Three Hundred and Twenty Two Only 2322

CHECKLIST
Check List of mandatory Documents to be attached as mentioned below:
Copy of Treating Physicians prescription (Duly signed & Stamped)
Original Receipts for purchase of prescribed medication (With name & date of the Patient)
Copy of Lab reports.
Copy of eye card for the reimbursement of Glasses claim
Copy of Vaccination Card
For Dental claim, detailed bill with teeth numbers and x-rays (taken during the treatment).
Note : Above mentioned Check List is according to the requirements by the insurance company for smooth and timely claim
processing, in case of any missing document/information claim processing can be stopped by the insurance company.

DECLARATION
I hereby declare that the amounts stated above are correct and was incurred by me for medical expenses.

Date: Signature of Employee:

Telenor HR Signatory and stamp