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GROUP MEDICAL INSURANCE CLAIM FORM
SECTION 1: 70 BE CONPLETED BY POLICYHOLDER & INSURED PERSON
Please tick the ype oflaim and use 1 claim form per member 1 Group Inpatient Claim Group Outpatient Ci
COMPANY'S NAME : POLICY NO.
PART A: TO BE COMPLETED BY EMPLOYEE & / OR DEPENDANT
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PART B: DETAILS OF ILLNESS / ACCIDENT
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PART 0: EMPLOYEE'S BANK DETAILS
Fo imbursrent cect ito your bank account. please provide you bank deals balou. Ht designated wocoont provided afer Pom our record passe
‘entact Aviva ato jour serves rckeraget fr “Change oa Arcoun or fo eles he henge.
Note ayant il no be mace to employer unl por grerent was mad by employer wth Avha Li.
PART D: MEDICAL INFORMATION AUTHORISATION
(IN part ast Sey He pe or pron prey arkan hep bbw 2 yuo)
[herby authorise five Lt resuas Kom any hospi, physician, poraon cr organisational fonnaton with eapctt any ils ius ia history,
soneutatns, preceiptions or trestmont, and copies of all horpal or redial rcords concerning ma at any time and authorise the prox menfcnod
covganisaton to dstlose al sch formation to Ava Lid. A photceopy of his authorsaionshallba considered at oective and val asthe original
| eecare thal th statemants and answers slated are rue an completo the best of my knouledge ae belt
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PART E: TO BE COMPLETED BY EMPLOYER [NOT APPLICABLE FOR PREFERREDUARE PLUS POLICIES]
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_FOR AVIVALLTD'S USE ONLY
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