Medical Claim Form

Please fill out all details

First Name ( Poora Naam) *

Last Name *

Who is the claim for? (Yeh claim kis k lien hai) *

Self (Apna)

Mother (Ammi)

Father (Abu)

Spouse (Biwi)

Children (Bachy)

What type of claim is? (Claim ki kea kism hai) *

Consultation (Mushawarat)

Medicine (Dawa)

Test (Jaanch)

Hospitalization (Hospital me daakhla))

Other (Degar)

Symptoms (Ilamat)

Test Amount in Rs.

Consultation Amount (Mushawarat ki raqam) *

Consultation Amount is Rs.

Medicines Amount (Dawa ki raqam)

Test Amount in Rs.

Test Amount (Jaanch ki raqam) *

Test Amount in Rs.

Select Venture

Select your venture

Filmzya
Brandlocus
Ahmad & Qadeer Holdings
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Upload Claim Document & Bills. (Claim k dastavaiz or bills yahn attach karen) *

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