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Forms

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
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 Confirmaiton 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)
2.2.6 Physician's Statement – S-2 (for Disability due to sickness)
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
3.1.8 Reassignment Notice
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)
4. Misc Forms
4.1 Complaint Form