CLAIM FORM_Personal Accident - Groupama

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CLAIM FORM_Personal Accident - Groupama Powered By Docstoc
					CLAIM FORM_Personal Accident
I/The Insured’s information
Full name:                                                                  Date of birth:            /      /      0           ID No:
Company (Policyholder):
Policy No:                                                                  Plan:                                               Effective Date:             /        /
Tel:                                                                        Email:


II/The treatment information
Accident/disease description
Cause :

Time and place of accident:


Description of accident / Symptom and Diagnosis:




Hospitalization period:
Treatment place:
Name and Address/Tel of the Third Party related to the Accident :


Have you (The Insured) ever had the same injuries/diseases before?                                                                              Yes/ No
If yes, please let us know the details (time, cause, percentage…)
....................................................................................................................................................................................
....................................................................................................................................................................................
III/List of claim amount(s):
 No         Date of prescription                            Invoice No                                Amount (VN )                                              Note
1
2
3
4
5
6
7
8
9
10
                                       Total


Related Documents:
    Prescriptions                      Invoices/ Receipts         Surgery report            Certificate of disability
    Hospitalization cartificate         Medical report                                       ID/passport
    Attendance card                     Social Insurance Certificate
   Labor contract (if the Insured is the new and has no name in the insured list)
* In case of traffic accident:          Police report             Driving license            Vehicle registration card
* In case of labour accident:           Labor accident report certified by the employer
* In case of death:                     Death Certificate         Heir-at-law Certificate
                                        True copy of marriage certificate (if the beneficiary is the spouse)
                                        True copy of birth certificate (if the beneficiary is the child)
                                        True copy of Family Record Book (if the beneficiary is the parents)
   Others (if any)
Payment method request by the Insured:            Cash           Bank Transfer
The Beneficiary’s information:
Full name:   __________________________________________________________________________________________
Address :______________________________ Tel: __________________________________________________________
ID/Passport : ____________________________Date: _______________________                 Place: __________________________
Bank account No :______________________________
Name of bank: ________________________________________________________________________________________
Bank address:_________________________________________________________________________________________


Declaration of the Policyholder and the Insured:
I declare that the above-mentioned statements are true and allow, on the form, my practitioner, hospital, clinic or medical
centre to furnish all my heath particulars to GROUPAMA and their representatives if requested.
Date:    /    /                                                  Date:    /    /    0
For the Insured                                        Confirmation of the Policyholder
(Name and sign)                                                 (Stamp and sign)

				
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posted:2/9/2013
language:English
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