2nd floor, Jubilee Insurance House I.

I Chundrigar Road Karachi

For Claim queries, please contact TEL: 021- 3565 7885-6 Email: grouphealth.claims@jubileehealth.com

SECTION 1 (TO BE COMPLETED BY EMPLOYEE)

Company Name ---------------------------------------------------------------------------------------- Employee Name --------------------------------------------------------

Patient Name ------------------------------------------------------------------------------------------------- Relation ------------------------------------------------------------

Policy # ---------------------------------------------------------- JGI ID ---------------------------- Amount of Claim------------------------------------------------------------

I, the above named employee declare that the information given in this form is correct to the best of my knowledge. I hereby authorize any
hospital or doctor/surgeon who has attended to me or to my family members to furnish to the Jubilee General Insurance (The Company) any
information they may require concerning our medical history, examination or treatment etc.
Employee Signature
With Date -------------------------
-------

SECTION 2 (TO BE COMPLETED BY ATTENDING PHYSICIAN/SURGEON)

Name of Patient ------------------------------------------------------------------------------------------------------------------------------ Age ----------------------------------

Name & Address of Referring Doctor (If any) ----------------------------------------------------------------------------------------------------------------------------------

Name of Physician/Surgeon --------------------------------------------------------------------------------------------------------- PMDC No -------------------------------

Name of Hospital & Address ----------------------------------------------------------------------------------------------------------- Ph No -----------------------------------

Source of Admission: Emergency Elective / Planned Others

Patient Registered as: Bed patient Out Patient

Date of Admission ------------------------------------------------------------------------------------- Date of Discharge ------------------------------------------------------

Presenting Complaints and Duration ---------------------------------------------------------------------------------------------------------------------------------------------

Associated Disease & Duration ----------------------------------------------------------------------------------------------------------------------------------------------------

Previous Medical/Surgical history with Diagnosis & Duration -------------------------------------------------------------------------------------------------------------

Date of Operation (If applicable) ------------------------------------------------------ Final Diagnosis -----------------------------------------------------------------------

Treatment given during hospitalization including detail of all investigations and medications:

---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Doctor’s Signature/Date ------------------------------------------ Hospital Seal with Authorized Signature ------------------------------------------------------------

SECTION 3 (VERIFICATION BY POLICY HOLDER/EMPLOYER – PLEASE ENSURE COMPLETION OF SECTION 1 & 2)

Name of Employer ----------------------------------------------------------------------------------------------------------------- Policy # --------------------------------------

Employee Name ------------------------------------------------------------------------------------------------------------ Designation ---------------------------------

Name & Designation of Authorized Person--------------------------------------------------------------------------------- Date -------------------------------------------

Company Seal with Signature -----------------------------------------------------------------------------------------------------------------------------------------------------

 IN CASE OF EMERGENCY HOSPITALIZATION

INCASE OF PANEL HOSPITAL IN CASE OF NON- PANEL HOSPITAL

 Approach any nearest Jubilee General Panel
hospital with our health Card
 Identify yourself as a Jubilee General Insured
 Produce Health Card
 Get the Treatment on credit up to available limit.
 Pay only the amount that exceeds the
entitlement(if any) before discharge
 Get the treatment at any nearest hospital
 Inform Jubilee General within 24 hours of the
hospitalization
 Pay cash for the Treatment
 Submit all original bills/supporting documents *
with our claim form for reimbursement within 30
days of discharge from the hospital
 Settlement of claim will be done in line with the
policy/terms.

IN CASE OF NON EMERGENCY HOSPITALIZATION

INCASE OF PANEL HOSPITAL IN CASE OF NON- PANEL HOSPITAL

 Approach any Jubilee General Panel hospital
with our health Card
 Identify yourself as a Jubilee General Insured
 Produce Health Card
 Get the Treatment on credit up to available limit.
 Pay only the amount that exceeds the
entitlement(if any) before discharge
 Send us the estimated cost from the concern
doctor/hospital for the treatment with
details/breakup for prior approval
 Jubilee General will approve case as per the
Jubilee General Panel Hospital rates and Policy
terms & conditions.
 Get the treatment and Pay cash for the
Treatment
 Submit all original bills/supporting documents *
with our claim form for reimbursement within 30
days of discharge from the hospital.
 Reimbursement of claim will be done in line with
prior approval and Jubilee General Payment
Terms with panel hospital.

*Supporting Documents

 Duly Filled Jubilee General Claim Form

 Original Itemized Bill/Invoice (Breakup of charges) on hospital bill book
 Discharge card/clinical summary and diagnostic reports
 Copy of Jubilee General Health Card
 Doctors Prescriptions
 Pharmacy Vouchers in original
 Original Payment receipts
 Copy of Birth Certificate (Hospital/Municipality for Maternity Claim)
 Jubilee General Approval Letter
 Any other relevant documents.

Note: Admissions only for Investigations/Work up are excluded