Allianz Sri Lanka | Notify Reimbursement Indoor Medical Claim

HOSPITAL AND SURGICAL REIMBURSEMENT INSURANCE CLAIM NOTIFICATION

Important Notice : Please complete a claim form for each claimant separately.

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1. INSURED DETAILS

Policy No

Name of Claimant

Name of Employer (if Applicable)

Contact No

Nature of Illness/injury or Treatment Obtained

EPF / EMP ID (if Applicable)

National ID

Name of Employee / Policy Holder

Date

DD/MM/YYYY

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DECLARATION

By submitting this form, you declare that the above information is true and accurate and understand that if you have in this or any further declaration in respect of this claim, made any false or fraudulent statement or suppress, conceal or falsely state any material fact whatsoever, your claim may be refused.

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Notify Reimbursement Indoor Medical Claim

HOSPITAL AND SURGICAL REIMBURSEMENT INSURANCE CLAIM NOTIFICATION

1. INSURED DETAILS

DECLARATION

How can we help you?

Need individual support or more information?

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