Documente Academic
Documente Profesional
Documente Cultură
10 Queens Road
Parktown, 2193
PO Box 31983
Braamfontein, 2017
The issue of this form does not constitute an admission of liability under the policy. Should this claim be approved, the payment will automatically be credited to the
account from which your premiums are collected, unless that account is a credit card account, in which case an alternative account number should be provided.
If payment is to be credited to an alternative account, please provide the relevant details in part 7 below
POLICYHOLDER
Name:
a Illness
Postal Address:
b Pregnancy
Accident
Nature of illness:
Email address:
Cell:
ID:
Tel: (Daytime)
Fax:
1. POLICY NUMBER(S)
5b. DETAILS OF PREGNANCY
Approximate date of conception
Date of delivery:
5c. DETAILS OF ACCIDENT
Date of accident:
2. PATIENT
Details of accident:
Name:
ID:
Injuries sustained:
Relationship to Policyholder:
Occupation:
Tick applicable
Name:
Postal Address:
Tel: (Daytime)
Fax:
4. HOSPITAL
Code:
Cell:
7. BANKING DETAILS
Fax:
Attending doctor:
Account Number
Account Holders Name
Tel No:
Fax:
Admission Date:
Time:
Type of Account
Discharge Date:
Time:
Branch Code
Should banking details stated above differ from that of your debit order,
please submit a bank statement/cancelled cheque with your claim form.
Signed:
AIG Life South Africa Limited is a Licensed Financial Services Provider FSP No. 15804 Reg. No. 2001/016602/06
AIG
10 Queens Road
Parktown, 2193
PO Box 31983
Braamfontein, 2017
Name:
a Illness
Postal Address:
Code:
Fax:
b Pregnancy
Accident
Tel (Daytime)
1. POLICY NUMBER(S)
Date of accident:
Details of accident:
3. PATIENT:
Injuries sustained:
Name:
ID:
4. DETAILS OF FAMILY/PATIENTS DOCTOR
From:
To:
Congenital conditions
Chronic defects/conditions
Mental diseases or disorders
Abuse of alcohol
Fax:
Tel (Daytime):
7. DECLARATION
I declare that the information given above, is, to my knowledge and belief, true and complete.
Date:
AIG Life South Africa Limited is a Licensed Financial Services Provider FSP No. 15804 Reg. No. 2001/016602/06
April 2013
aqula-aig057
Doctors signature: