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AIG

10 Queens Road
Parktown, 2193
PO Box 31983
Braamfontein, 2017

T 0860 113 522


F +27 11 551 8298
directclaimsa@aig.com
www.aig.com

Hospitalisation Claim Form SECTION 1


To be completed by the Policyholder

The issue of this form does not constitute an admission of liability under the policy. Should this claim be approved, the payment will automatically be credited to the
account from which your premiums are collected, unless that account is a credit card account, in which case an alternative account number should be provided.
If payment is to be credited to an alternative account, please provide the relevant details in part 7 below
POLICYHOLDER

5. REASONS FOR HOSPITALISATION (applicable box)

Name:

a Illness

Postal Address:

b Pregnancy

Accident

5a. DETAILS OF ILLNESS


Code:

Nature of illness:

Email address:

When did patient become aware of illness?

Cell:

ID:

Has patient suffered from this condition before?

Tel: (Daytime)

Fax:

If yes, give dates and details of treatment:

1. POLICY NUMBER(S)
5b. DETAILS OF PREGNANCY
Approximate date of conception
Date of delivery:
5c. DETAILS OF ACCIDENT
Date of accident:
2. PATIENT

Details of accident:

Name:
ID:

Injuries sustained:

Relationship to Policyholder:
Occupation:

6. REQUIRED SUPPORTING DOCUMENTS

3. GENERAL PRACTITIONER (USUAL FAMILY DOCTOR)

Tick applicable

Name:

A detailed hospital account

Postal Address:

Medical history from the family doctor


ID:

Tel: (Daytime)

Fax:

Day to Day treatment charts including all medication


received during stay

4. HOSPITAL

A detailed motivation letter from the attending Specialist


(not from a GP). A two-liner motivation will not be considered.

Please attach copies of hospital account.


Name of hospital:
Tel No:

All historical, radiological and pathological reports and


investigations (including all bloodwork-ups), x-ray reports,
specialist reports, MRI reports, CAT Scans etc)

Code:
Cell:

7. BANKING DETAILS
Fax:

Attending doctor:

Account Number
Account Holders Name

Tel No:

Fax:

Name of Bank/Building Society

Admission Date:

Time:

Type of Account

Discharge Date:

Time:

Branch Code
Should banking details stated above differ from that of your debit order,
please submit a bank statement/cancelled cheque with your claim form.

8. DECLARATION AND AUTHORISATION BY POLICYHOLDER OR LEGAL REPRESENTATIVE


I certify that the banking details are correct, failing which AIG Life South Africa Limited is absolved against all direct losses, liabilities, suits, proceedings, costs,
claims, demands, charges and expenses (including all legal and professional fees and disbursements) in respect thereof. I accept that it is my responsibility to
inform AIG Life South Africa Limited of any changes in my banking details, failing which AIG Life South Africa Limited will accept no liability for changes which are
not communicated or communicated timeously.
I further declare that the information given is true and complete to the best of my knowledge and belief and authorise any hospital, physician or other person who
has attended to me to furnish to AIG Life South Africa Limited or its representatives any and all information with respect to any sickness or injury, medical history,
consultations, prescriptions or treatment, and copies of all hospital records, including the results of all tests undergone by me or the patient. I agree that a photocopy of this authorisation shall be considered as effective and as valid as the original
Date:

Signed:

AIG Life South Africa Limited is a Licensed Financial Services Provider FSP No. 15804 Reg. No. 2001/016602/06

AIG
10 Queens Road
Parktown, 2193
PO Box 31983
Braamfontein, 2017

T 0860 113 522


F +27 11 551 8298
directclaimsa@aig.com
www.aig.com

General Practitioners Report SECTION 2


To be completed by patients usual Family Doctor, who has known patient for 2 years or longer
Note: This page needs only be completed by patients usual Family Doctor if: (1) the policy is less than 24 months old, or (2), the benets were increased less than 24
months ago, or (3), the patient was added to the policy less than 24 months ago. The issue of this form does not constitute an admission of liability under the policy.
The Policyholder is responsible for payment of any fee in connection with the completion of this declaration
HOW LONG HAVE YOU BEEN THE PATIENTS FAMILY DOCTOR?

5. REASONS FOR HOSPITALISATION (applicable box)

Name:

a Illness

Postal Address:
Code:
Fax:

b Pregnancy

Accident

5a. DETAILS OF ILLNESS


Nature of illness:
When did patient become aware of illness?

Tel (Daytime)

Has patient suffered from this condition before?


If yes, give dates and details of treatment:

1. POLICY NUMBER(S)

5b. DETAILS OF PREGNANCY


Approximate date of conception
Date of delivery:
5c. DETAILS OF ACCIDENT

2. NAME OF POLICY HOLDER:

Date of accident:
Details of accident:

3. PATIENT:

Injuries sustained:

Name:
ID:
4. DETAILS OF FAMILY/PATIENTS DOCTOR
From:

To:

If less than 24 months, state previous doctors details.


Name:
Postal Address:
Code:

6. WAS HOSPITALISATION IN ANY WAY CONNECTED


TO (applicable box)

Congenital conditions
Chronic defects/conditions
Mental diseases or disorders
Abuse of alcohol

Fax:

Drugs not administered on or in accordance with advice


of a doctor

Tel (Daytime):

Self-inicted injury/attempted suicide


HIV/AIDS related conditions/illnesses
Miscarriage, abortion or any complication therefrom
Details:

7. DECLARATION
I declare that the information given above, is, to my knowledge and belief, true and complete.
Date:

AIG Life South Africa Limited is a Licensed Financial Services Provider FSP No. 15804 Reg. No. 2001/016602/06
April 2013

aqula-aig057

Doctors signature: