AIG

Sandown Mews West T 0860 '1 13 522

88 Stella Street, 2196 F 011 551 8298
PO Box 31 983 ZA.ACCH.FNOL.EMEA@AIG.COM
Braamfontein,20lT w.aig.com

Hospitalisation Glaim Form SECTION 1

rhe issue or this rorm does nor consritute an admission ;fi:ltHi"o1}L'n:,fffi:"J'X3'fSloor"u"o, *e paymenr wiil auromaricaily be credited to rhe
"rT:r*i
account from which your premiums are collecled, unless that account is a credit card account, in which case an altemalive account number should be provided.
lf payment is to be credited to an alternative a6ount, please provide the relevant details in pan 7 below

ueE
When did patienl become aware ol
-coli'
Has patient suffered from this condition before? io fed"oo
lf yes, give dates and details of trealment:
h hlqjdef

Mediml history from the family doctor

All historical, radiological and pathological reports and
investigations (including all bloodwork-ups), x-ray reports,
specialist reports, MRI reports, CAT Scans etc)

Day to Day treatment charts induding all medication

received during stay

A detailed motivation letter from the attending Specialist

Please attach copies of hospital acmunt. (not from a GP). Atlvo-liner motivation will not be considered

Should banking delails sfafed aboye differ from that of your debit order,
please submit a bank statement/cancelled cheque with your claim form.

I certiry that the banking details are coffect, 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 delails, failing which AIG Life South Africa Limiled will a€ept no liability for changes which are
not communiGted 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 turnish to AIG Life South Africa Limited or its representatives any and all infollglion with respect to any sickness or injury, medical history,
consultations, prescriptions or treatment, and copies of all hospital records, including the results
be considered as efiective and as valid as the original

AIG Life SouthAfrica Limited isa Licensed Financial Seruices ProviderFSP No. 15804 Reg. No.2001/016602/06
 LIFE PEGLERAE HOSPITAL(PTY) LTD
PR No 5808359
].73 BEYERS NAUDE DRIVE
LIFE PEGLERAE HOSPITAL (PTY) LTD RUSTENBURG, 0299
T/A PEGLERAE HOSPITAL P.O.BOX 244 RUSTENBURG O3OO
Reg . No .200L/ 0220e8 / 07

VAT No. 4800204440 Telephone 0]-4 5977200 - HOSPITAL

Facsimile Ol4 5927527 - HOSPITAL
Telephone 0]-I 219 9220 - ACCOUNTS
Facsimile 0856 858 812 - ACCOITNTS
VISIT NO .8700549292 ACCOI'NT DETAILS PAGE :-
IN-PATIENT 29JAN20l-8 14:05
---- GUARANTOR - ---- PATIENT -

MR R HAYES MR REUBEN HAYES

PO BOX 224 PO BOX 224
KROONDAL KROONDAL
KROONDAL KROONDAL
0350 03 50

WORK (0) 0-0 Ext.0 WORK (0) 0-0 Ext.0

HOME (0) 0-0 Ext.0 HOME (0) 0-0 Ext.0
ID 4904135005089 ID 49041-35005089
DOB I-3APR194 9 68y DOB 1-3APR194 9 58y

CURRENT PLATINUM HEAITH PRE AUTH APURM65693O

PLAN PLATCOMPREHENSIVE EB L.O.S. 5.0
MEMB No 49041-35005 Dep OO ADMIN PLATINUM ADMTNISTRATOR
CONF No
VAT No CYCLE CURRENT

VISIT/
BTLLING CLERK)
ADMIT PT HATTINGH/ B R, DR Pr. No 460L629
REFER Pr KRUGER/ A 'J, DR Pr. No ]-4568]-4
CPT/ICD CODES
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P ICD N]-O
s rcD 896.6
s rcD 895.5
C ICD I1O
c rcD E78.5
c rcD 272.0
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Standard Bank l November 20li
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Staattydperk ll

,lllli November 20li

tot

Staat Reken i n gvoorkeu rsentrunr I ]STENBURG

TANDARD BAN K] i enteskake] sentrum i,l 60 101 341

RUSTENBURG Rekeningbestuurder
ii,li::i60 101
BRANCH Te'l efoonnommer 341

e-p0s i ttf oOstandardbank, co, za

28 Nov 2017 Internet r,w,standardbank,co,za

3972 81 adsy ,van1

Datum ,iili:ii |rlovember 2017

Tvd | ,l : 19:43

Address : STAl,lD 574

Rekeni ngi dentifi kasi e t,tlATERKLOOF

Naan van Rekeningr Hayes R 0299

Reken i ngnonmer : 03 322 383 1

Transaksi ebesonderhede

Transaks i ebeskrywi ng

Begi nsal dostaat R 95,4i

EFFEKTETRUSTTERUGKOPE 97i4 I.IEDGROUP R 1,351,99

7000859 LA li1122
Saldo soos op 28 Novenber 2017 R 1, 35 1,99

**Hierdie fooie s'luit BThl teen 1{$ in

U moet asseb'lief a1le transaksies op hierdie staat nagaan en die bank s0 gou as noontlik rran teenstrydighede in kennis ste'l

Vandag se deb'iete is nog nie betaal nie