Title |
File |
Claim Form - GoLootlo Cardholders |
|
Agency Contract |
|
1. Group Health Family Takaful |
1.1.1 Family Health Questionnaire |
|
1.1.2 Enrollment Form |
|
1.1.3 Short Form Health Description |
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1.1.4 Additions of Member |
|
1.1.5 Deletions of Member |
|
1.1.6 Fluctuation – Upgrade/Downgrade etc. |
|
1.1.7 Proposal Request Form - Health |
|
1.1.8 Group Health Takaful Confirmation Form |
|
1.2 Claim Services |
1.2.1 Pre-Authorization Information Form |
|
1.2.2 Hospitalization Reimbursement Claim Form |
|
1.2.3 Out-patient Reimbursement Claim Form |
|
2. Group Term Family Takaful |
2.1.1 Health Questionnaire (for takaful coverage above FCL) |
|
2.1.2 Additions of Member |
|
2.1.3 Deletion of Member |
|
2.1.4 Fluctuation – Upgrade/Downgrade etc. |
|
2.1.5 Group Term Takaful Confirmation Form |
|
2.1.6 Nomination Form |
|
2.1.7 Declaration of Good Health |
|
2.2 Claim Services |
2.2.1 Employer’s Statement – D1 (for Death Claim) |
|
2.2.2 Physician's Statement – D2 (for Death Claim) |
|
2.2.3 Employer’s Statement – DS-1 (for Disability due to Accident) |
|
2.2.4 Physician's Statement – DS-2 (for Disability due to Accident) |
|
2.2.5 Employer’s Statement – S-1 (for Disability due to Sickness) |
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2.2.6 Physician's Statement – S-2 (for Disability due to sickness) |
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2.2.7 Corporate AML Questionnaire |
|
2.2.8 Corporate Due Diligence Form |
|
3. Individual Family Takaful |
3.1.1 Change in Contact Detail |
|
3.1.2 Change In Nominee |
|
3.1.3 Withdrawal Form |
|
3.1.4 General Services Request (GSR) |
|
3.1.5 Assignment Notice - Company |
|
3.1.6 Assignment Notice – Loved Ones |
|
3.1.7 Assignment Notice - Provident Fund |
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3.1.8 Reassignment Notice |
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3.1.9 Special Illustration Request Form |
|
3.1.10 Declaration of Health & Occupation (DHO) |
|
3.1.11 Non-Medical Application Form |
|
3.2 Claim Services |
3.2.1 Claimant’s Statement (for Death Claim) |
|
3.2.2 Physician's Statement (for Death Claim) |
|
3.2.3 Claimant’s Statement (for Disability/Illness Claims) |
|
3.2.4 Physician's Statement (for Disability/Illness Claims) |
|
3.2.5 Claim Intimation Form |
|
3.2.6 EDD - Individual Life Claim |
|
4. Misc Forms |
4.1 Complaint Form |
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