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OPD Dental Claim Form Instructions

Century Insurance Company Limited provides an outpatient claim form for employees to submit claims for reimbursement of medical expenses. The form collects information such as the employee's name and ID number, dates of service, names of medical practitioners and laboratories, amounts claimed, and requires signatures. To be reimbursed, employees must attach original receipts and bills from physicians and laboratories along with diagnostic reports and documents related to the medical services received.

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42 views1 page

OPD Dental Claim Form Instructions

Century Insurance Company Limited provides an outpatient claim form for employees to submit claims for reimbursement of medical expenses. The form collects information such as the employee's name and ID number, dates of service, names of medical practitioners and laboratories, amounts claimed, and requires signatures. To be reimbursed, employees must attach original receipts and bills from physicians and laboratories along with diagnostic reports and documents related to the medical services received.

Uploaded by

4Ever Videos
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

CENTURY INSURANCE COMPANY LIMITED UAN 111-111-717

LAKSON SQUARE, BUILDING NO.3, SARWAR SHAHEED ROAD, KARACHI-74200 Tel 35698000
Fax 92-21-35671665
Website [Link]
E-mail info@[Link]

OUT PATIENT CLAIM FORM

 OPD /  DENTAL For CICL use only


Date :   
Claim Amount

Company Name : Approved Amount

Deduction
Employee      I.D.  Amount
Number Reason(s)
Employee's Name 
& Designation Checked by:

Bill No. Claim Amount


Date
S. No. or Name of the Medical Practitioner and Laboratory Family
(dd/mm/yy) Self Spouse/Children (if
Receipt No. covered)

         

           

         

         

         

       

       

       

       

       

       

       

       

Sub Total :

Total Claim Amount :

Amount in words:

Employee's Signature H.O.D's Signature Employer's Signature with Seal

Documents to be attached:
● Proper original receipts/bills of attending Physician with detail of charges
● Proper original receipts/bills of Lab. Test, X-Rays etc. and copies of reports/diagnosis and other related document

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