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    Century Insurance Company Limited: OPD Dental

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    4Ever Videos
    Century Insurance Company Limited provides an outpatient claim form for employees to submit claims for reimbursement of medical expenses. The form collects information such as the employee's name and ID number, dates of service, names of medical practitioners and laboratories, amounts claimed, and requires signatures. To be reimbursed, employees must attach original receipts and bills from physicians and laboratories along with diagnostic reports and documents related to the medical services received.

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    Century Insurance Company Limited: OPD Dental

    Uploaded by

    4Ever Videos
    66 views1 page
    Century Insurance Company Limited provides an outpatient claim form for employees to submit claims for reimbursement of medical expenses. The form collects information such as the employee's name and ID number, dates of service, names of medical practitioners and laboratories, amounts claimed, and requires signatures. To be reimbursed, employees must attach original receipts and bills from physicians and laboratories along with diagnostic reports and documents related to the medical services received.

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    MedicalInsuranceForm

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    Century Insurance Company Limited provides an outpatient claim form for employees to submit claims for reimbursement of medical expenses. The form collects information such as the employee's name and ID number, dates of service, names of medical practitioners and laboratories, amounts claimed, and requires signatures. To be reimbursed, employees must attach original receipts and bills from physicians and laboratories along with diagnostic reports and documents related to the medical services received.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    66 views1 page

    Century Insurance Company Limited: OPD Dental

    Uploaded by

    4Ever Videos
    Century Insurance Company Limited provides an outpatient claim form for employees to submit claims for reimbursement of medical expenses. The form collects information such as the employee's name and ID number, dates of service, names of medical practitioners and laboratories, amounts claimed, and requires signatures. To be reimbursed, employees must attach original receipts and bills from physicians and laboratories along with diagnostic reports and documents related to the medical services received.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    CENTURY INSURANCE COMPANY LIMITED UAN 111-111-717

    LAKSON SQUARE, BUILDING NO.3, SARWAR SHAHEED ROAD, KARACHI-74200 Tel 35698000
    Fax 92-21-35671665
    Website www.cicl.com.pk
    E-mail info@cicl.com.pk

    OUT PATIENT CLAIM FORM

     OPD /  DENTAL For CICL use only


    Date :   
    Claim Amount

    Company Name : Approved Amount

    Deduction
    Employee      I.D.  Amount
    Number Reason(s)
    Employee's Name 
    & Designation Checked by:

    Bill No. Claim Amount


    Date
    S. No. or Name of the Medical Practitioner and Laboratory Family
    (dd/mm/yy) Self Spouse/Children (if
    Receipt No. covered)

             

               

             

             

             

           

           

           

           

           

           

           

           

    Sub Total :

    Total Claim Amount :

    Amount in words:

    Employee's Signature H.O.D's Signature Employer's Signature with Seal

    Documents to be attached:
    ● Proper original receipts/bills of attending Physician with detail of charges
    ● Proper original receipts/bills of Lab. Test, X-Rays etc. and copies of reports/diagnosis and other related document

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