Allianz HealthCare Allianz HealthCare - Benefits Sheets and Premiums Chart Proposal Form

Local arm of the world’s number 1 brand in insurance, Section I - Medical & Hosptalisation Cover
Your VAT No :
Allianz Insurance Lanka Limited introduces Allianz Benefits BRONZ SILVER GOLD PLATINUM
Any one Year 250,000.00 500,000.00 750,000.00 1,000,000.00 Intermediary Name :
HealthCare which is specially designed to suit all your Any one Event 185,000.00 375,000.00 625,000.00 875,000.00 Code :
Health needs.
Room Charges - Per day (Including ICU charges) 8,500.00 10,500.00 12,500.00 15,500.00
Your health is precious to you - it enables you to live your Hospital and nursing home maintenance charges including admission fees. 40,000.00 70,000.00 125,000.00 135,000.00
Please Fill in BLOCK LETTERS

life the way you please. But a sudden illness or accident can Proposer’s Full Name : Mr /Mrs / Miss / Dr / Rev.
Medical and operational expenses for treatment and nursing provided on the
put a stop to your way of living and empty your savings. recommendation of a consulting specialist and for the use of the operating 100,000.00 185,000.00 360,000.00 450,000.00 ..........................................................................................................................................................................
theater.
Protect yourself with the Allianz HealthCare medical ...........................................................................................................................................................................
Operations, surgeon's & anesthetist's fees, consultant's and specialist's fees,
insurance plan that covers you against medical expenses Address :
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specialist services including deep therapy treatment, x-rays, radiological and 30,000.00 100,000.00 110,000.00 250,000.00
for hospitalization, in the event that you fall ill or meet with radium examination and treatment, electrical treatment
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an accident. Now you don't ever have to worry about not Drugs and other medical expenses 15,000.00 20,000.00 30,000.00 40,000.00
NIC / Passport No :
having enough money for treatment in case things go
Emergency Travelling 3,000.00 3,000.00 5,000.00 7,500.00
wrong.
2,000 per day 2,000 per day 2,000 per day 2,000 per day Date of Birth :
With the Increasing cost on medical treatment, Allianz Hospitalization in a non paying ward of a Government Hospital upto 30,000 upto 30,000 upto 30,000 upto 30,000
HealthCare is the perfect solution for you and your family. Occupation :
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Expenses incurred whilst being hospitalised in a non paying ward of a Upto the event Upto the event Upto the event Upto the event
Government Hospital limit limit limit limit
Exclusive benefits of Allianz HealthCare Contact Details : M o b i l e
Excess 10% 10% 10% 10% T e l e p h o n e
 Optional covers for Critical Illnesses & Personal
Section II - Critical Ilness Cover (Limit Per Member) - 5 major critical illnesses
Accidents Email :
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Critical Illness - 250,000.00 500,000.00 750,000.00 1,000,000.00
 Extended to cover overseas treatment Section III - Personal Accident Cover Period of Insurance : From ...........................................................................
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 Emergency travelling expenses Personal Accident cover (Sum Insured Per Member) 125,000.00 250,000.00 375,000.00 500,000.00 to .....................................................................................
Insured and Spouse - Capital benefits only
 Day surgery cover Funeral Expenses - death due to Accident only 20,000.00 25,000.00 30,000.00 35,000.00 Section I
 Coverage for any number of children Annual Premium excluding taxes Section I In LKR Plan Details :
Individual Basis Bronze Silver Gold Platinum
 Critical Illness cover for 5 major illnesses Male 15,725.00 31,875.00 53,125.00 74,375.00
Female 18,870.00 38,250.00 63,750.00 89,250.00
 No claim bonus Child 11,793.75 23,906.25 39,843.75 55,781.25 Section II
 Discount on selected hospitals Family Basis
Select :
 Family discounts Family Premium 30,000.00 60,000.00 90,000.00 120,000.00 Individual Family Plan
Annual Premium excluding taxes Section II In LKR
 Medical tests payments under goverment hospital.
Premium Per Person 15,000.00 30,000.00 45,000.00 60,000.00 Section III
 Cataract surgeries Annual Premium excluding taxes Section III - Section III In LKR Select :
Premium Per Person 250.00 500.00 750.00 1,000.00
Individual Family Plan
All premiums stated above are excluding taxes
 Additional Features
How to make my claim
Disablement suffered or  Age Limit - 1 year to 70 years Hospitalisation – Direct Settlement
Any Illness / Disease /

 Policy is extended to cover HIV and AIDS related - Contact Call Centre HealthCare
suffering from

complex - Register the claim

 60 days waiting period excluding accidental - Submit Allianz cashless card at the admission
hospitalization - Contact call centre once discharged.
 Direct settlement facility (Only at empanelled
hospitals) Critical Illness
- Claim Form
Relationship to the

Five major Critical Illnesses

- Diagnosis card
 Coronary Artery Bypass
Insured

- Hospital bills & Receipts

Self

 Cancer
- All duly stamped original payment receipts
 Renal Failure
- Any other documents specifically required
 Benign Brain Tumor
 Strokes
Personal Accident / Funeral Expenses
Special Notes (If applicable)
- Claim Form
NIC

...................................................................................................... - Medical reports

...................................................................................................... - Death Certificate

...................................................................................................... - Postmortem Reports

DOB

- Police Statement
......................................................................................................
- Inquest proceedings

If required further information please contact Gayan

or Lahiru 011 2 317 948
Full name

Allianz Insurance Lanka Limited ALLIANZ HEALTHCARE HOT LINE

No.46/10, Nawam Mawatha,
Colombo 02, Sri Lanka 011 2 317 917
Tel: +94 112 300 400 Fax: +94 112 304 404
Email: info@allianz.lk Website: www.allianz.lk

Head Office - Tel: +94 112 317 948 Fax: +94 112 304 404