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    Formulir BNI Life

    Uploaded by

    Adhyartha Keraf
    This document is a reimbursement claim submission form containing fields for the claimant's information such as name, member number, patient's name and relationship to the member, policy number, company name, product name, completeness of submitted documents including claim form, medical records, original receipts, cost details, prescriptions, diagnostic tests, tax invoices or receipts for overseas treatment. It also contains fields for the claimed amount, amount in words, contact details, email address, bank account information and signature of the member or patient.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Formulir BNI Life

    Uploaded by

    Adhyartha Keraf
    459 views1 page
    This document is a reimbursement claim submission form containing fields for the claimant's information such as name, member number, patient's name and relationship to the member, policy number, company name, product name, completeness of submitted documents including claim form, medical records, original receipts, cost details, prescriptions, diagnostic tests, tax invoices or receipts for overseas treatment. It also contains fields for the claimed amount, amount in words, contact details, email address, bank account information and signature of the member or patient.

    Original Description:

    Formulir Klaim Asuransi BNI

    Copyright

    © © All Rights Reserved

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    This document is a reimbursement claim submission form containing fields for the claimant's information such as name, member number, patient's name and relationship to the member, policy number, company name, product name, completeness of submitted documents including claim form, medical records, original receipts, cost details, prescriptions, diagnostic tests, tax invoices or receipts for overseas treatment. It also contains fields for the claimed amount, amount in words, contact details, email address, bank account information and signature of the member or patient.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    459 views1 page

    Formulir BNI Life

    Uploaded by

    Adhyartha Keraf
    This document is a reimbursement claim submission form containing fields for the claimant's information such as name, member number, patient's name and relationship to the member, policy number, company name, product name, completeness of submitted documents including claim form, medical records, original receipts, cost details, prescriptions, diagnostic tests, tax invoices or receipts for overseas treatment. It also contains fields for the claimed amount, amount in words, contact details, email address, bank account information and signature of the member or patient.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    FORMULIR PENGAJUAN KLAIM REIMBURSEMENT

    SUBMISSION FORM OF REIMBURSEMENT CLAIM

    1. Nama Peserta : ………………………………………………………………………………………………………


    Name of Member

    2. Nomor Peserta : ………………………………………………………………………………………………………


    Number of Member

    3. Nama Pasien : ………………………………………………………………………………………………………


    Name of Patient

    4. Status Pasien : Sendiri / Suami / Istri / Anak


    Status of Patient Self / Husband / Wife / Child

    5. Nomor Polis : ………………………………………………………………………………………………………


    Number of Policy

    6. Nama Perusahaan : ………………………………………………………………………………………………………


    Name of Company

    7. Nama Produk Yang Diambil : ……………………………………………………………………………………………


    Name of product

    8. Kelengkapan dokumen yang disampaikan / Completeness of documents submitted :


    Formulir klaim yang diisi lengkap / Claim Form which is already fill in completely
    Resume medis / Medical Resume
    Kuitansi pembayaran asli / Original Payment Receipt
    Rincian biaya / Detail Cost
    Salinan resep / Copy of prescription
    Salinan tes diagnostik (laboratorium, hasil radiologi, dll) / Copy of the Diagnostic Test (Laboratory Result, Radiology, etc)
    Tax invoice atau Official Receipt (untuk perawatan diluar negeri) /Tax Invoice or Original Receipt (for overseas treatment)
    Lainnya / others ……………………………

    9. Jumlah Klaim Diajukan / Amount of Submitted : ………………………………………………………………………………....

    10. Terbilang / Amount of Words : ……………………………………………………………………………………………

    11. No. Telepon Kantor/HP/Rumah : ……………………….…../………………..………..…../………………..………….....


    Phone No. of Office/ Handphone/Home

    12. Alamat Email (Email Address) : ……………………………………………………………………………………………

    13. Informasi Nomor Rekening (apabila ada perubahan) / Information of Account No. (if there any change)
    Bank / Cabang / Bank/Branch : ……………………………………………………………………………………………
    No. Rekening / Account No. : …………………………………………………………………………………………….
    Atas Nama / On Behalf of : …………………………………………………………………………………………….

    , / / (Tempat/tanggal)
    (Place/Date)

    ( )
    (Nama Jelas & tandatangan Peserta atau Pasien
    (Name & Signature of Member or Patient)

    PT BNI Life Insurance

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