Alico Indemnity Medical Claim Form
Alico Indemnity Medical Claim Form
Administrative Office
P.O. Box 5984, Sharjah, United Arab Emirates
Tel +971 6 556 2566 Fax + 971 6 556 4197
EMPLOYEES SECTION
Employee's Name & Date of Birth
Policy Number
CLAIM SUBMISSION PROCEDURE
To avoid any delays in the processing of your claim, please ensure that:
1. The claim is submitted through your employer. Please obtain the Group
Policy No. from your Employer.
2. All questions on the form are answered. Do not leave any blanks. Use block
letters.
3. All claim documents should be submitted either in English or Arabic.
Documents in other languages must be translated by an official public
translator prior to submission.
4. All necessary claims documents are to be submitted within 30 days of the
incurred date. Claims received after 90 days will not be processed.
The following original documents are to be attached:
Out Patient Treatment
1. Official receipt showing the attending physician's detailed charges along
with his stamp and signature
2. Itemized pharmacy bill showing the date of purchase, name of patient,
quantity and name of drugs along with the physician's prescription
3. Official receipt showing charges for each of the Lab. Test. X-ray films,
and other examinations done and supported by the respective physician's
request to undergo examinations and copies of the results of examinations
undertaken
In-Patient Treatment
1. Itemized hospital bill supported by the official hospital receipt for the total
amount paid.
2. Official receipt showing Attending Physician's or Surgeon's charges along
with his stamp and signature.
3. Detailed hospital discharge report.
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EMPLOYERS SECTION
Yes -
Assigned Provider -
Employee -
Payment Applies
No -
Wire Transfer
Banks Name
Employer Group -
Cheque
Swift Code
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AUTHORIZATION STATEMENT
I hereby certify that all answer and all documents submitted with the claim
form are complete and true. I hereby authorize any doctor, hospital, or medical
provider, any insurance company or any other company, institution or any other
person who has any record or information about me and/or any of my family
members to provide Metlife Alico (American Life Insurance Company) with the
complete information's, including copies of their records with reference to my
sickness or accident, any treatment, examination, advice, or hospitalization.
Any photocopy of this authorization shall be taken as the original copy.
DISCLAIMER
Employees Signature
ALICO IS A METLIFE, INC. COMPANY
MA/GCD/IMC-APP/GEN/02-11
2010 MetLife Alico
1921 ,
:
- 5984 ..
+971 6 556 4197 +971 6 556 2566
Chief Complains
Diagnosis
How long has the patient been suffering from this sickness?
Please specify the date symptoms first appeared.
( (