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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: [email protected] , 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 Physician’s Fee Medicines Prescribed Total Bill for this Visit Verified by authorised Officer of employer Signature of Employee Signature and seal of attending physician

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  • 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: [email protected], 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


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