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Adamjee Health Insurance Status Change Form

This document is a status change form (SCF) used by Adamjee Insurance Company Limited for making changes to health insurance policies. It provides instructions for adding or deleting dependents from a policy. When adding dependents, an employee must submit a completed health questionnaire form and provide documentation like a marriage or birth certificate. When deleting an employee, the original credit letter must be returned. The form also allows for changes in insurance categories, and requires the employee's credit letter number and an explanation for the change. The employer must sign and date the completed form.

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254 views1 page

Adamjee Health Insurance Status Change Form

This document is a status change form (SCF) used by Adamjee Insurance Company Limited for making changes to health insurance policies. It provides instructions for adding or deleting dependents from a policy. When adding dependents, an employee must submit a completed health questionnaire form and provide documentation like a marriage or birth certificate. When deleting an employee, the original credit letter must be returned. The form also allows for changes in insurance categories, and requires the employee's credit letter number and an explanation for the change. The employer must sign and date the completed form.

Uploaded by

aligrt
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Adamjee Insurance Company Limited

~amJ~

Health Insurance

Insurance

STATUS CHANGE FORM (SCF)

1. In case of an ADDITION of the dependant(s) like (spouse/children/parents) to an employee, please enclose duly filled Health Questionnaire Form
(HQF) along with original credit letter of the employee so that the revised credit letter can be issued.
'.

a) For addition of a spouse: Health Questionnaire Form (HQF) duly filled along with a copy of Marriage Certificate.
b) For addition of child: Health Questionnaire Form (HQF) duly filled along with a copy of Birth Certificate.
2. In case of a DELETION of an employee, please return the original credit letter for cancellation so that this may not be misused to our financial
detriment. However, for the deletions of any of his/her dependant(s) (parent/spouse/children), please return us the original credit letter only as
the same would be re-issued after incorporating the desired changes.
Name of Policy Holder/Company:

Policy No.:

Name of Employee:

ADDITIONS/DELETIONS:

SINo

Name of the person(s)


to be added/deleted

I
I

!
, Addition, Deletion
Please specify
I

:
I
i Date of Birth I
I
I
I

Credit
Letter No

I
I

Relationship
With The
Employee

!
:

Category/
Plan

Effective Date

I
I

1
2
3
4

5
6

CHANGE OF CATEGORY (please provide the copy of the letter as evidence for the change in category):
Employee's Name

S/No1

I Employee's Credit
I

Letter No.

Reason for the


change in category

EXisting Category

Revised Category

Effective Date

2
3
4
5

Signature

'&

Seal of the Employer

Date:

Adamjee Insurance Company Limited, Health Insurance Department, 3rd Floor, Tanveer Building, 27 C-III,
M. M. Alam Road, Guiberg-III, Lahore. Webside: [Link]

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