Out Patient Claim Form

THE UNIVERSAL INSURANCE COMPANY LIMITED

The Universal Insurance Co. Ltd Universal Insurance House 63, Shahrah-e-Quaid-e-Azam Lahore-54000, Pakistan

Tel: Off: 042-7353458- 7355426-7324194-7353453-7324222 Fax:042-7230326, 7353209 Email: health@uic.com.pk, Web: www.uic.com.pk

OUTPATIENT EXPENSE CLAIM FORM

Note:- Reimbursement will be subject to Provision of following:- a) Original cash memos of medical store duly printed with Tax No. b) Registered Doctors original prescription.

Name of Attending Physician :

Name of Employee :

Name of Employer :

S.Nos. Name of patient Date of

visit Complaint/ Diagnosis

Physicians Fee

Medicines Prescribed

Total Bill for this

Visit

Verified by authorised Officer of employer

Signature of Employee

Signature and seal of attending physician

Out Patient Claim Form

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