CAPITAL LIFE INSURANCE COMPANY LIMITED Medical Claim Form IMPORTANT NOTES: 1 Original Receipts only must be attached to the Claim Form 2._ Only persons declared on the proposal or application Form can be considered for a claim Claims not properly completed will be returned Which Organisation, Association, Superannuation Fund, Crédit Union are you a Nember of? Name of Employer: EMPLOYEE DETAILS Sumame: ___| Given Name(s): Membership Number: Postal Address: Mobile No.: Phone No.: Date Joined Medicare Scheme: Policy / Plan Type: The following Section must be fully completed and signed by the Member/Employee. Do any of the Medical or Professional Services claimed relate to the categories listed below? 1 Work-related incidents which entitles you to Workers Compensation Claim? Yes No 2 Motor Vehicle accident? Yes No 3. Drug Addiction, Alcoholism, Mental Illness or HIV / Aids? Yes No 4 Condition(s) that existed prior to joining the Medical Scheme? Yes No If you have answered “Yes” to any of the above questions, please provide details. DECLARATION | do solemnly and sincerely declare that the answers given above are true and accurate and that | have not with-held any relevant information. Further that | accept the consequences of not providing accurate {information and acknowledge that Capital Life Insurance Company Limited (hereinafter called the “Company”) reserves the right to repudiate my claim. | further authorise the Company to obtain from any Physician or organization that maintains records of my health, medical history or conditions for which treatments had previously been sought. A copy of this authorization shall be as effective and valid as the original. Signature of Claimant Date Level 2 Haus Tisa Walgani P O Box 1972 Port Moresby Telephone No, 325 1144 Facsimile 9232595GLTVAWAVLOU £8 CLINE | STaVAVa WVID W1OL ~-SUnLYNDIS: LNVAIVID 30 SVN ave W|sspax ssn | Wiow-ens wd Hla | = Trogegamar | 5) opens | oe coma | SH | pty | NORM | peccrmony | RIPEN | weacrmwo | aoe | foros | PIECE | ne | onto | oy anny TAVIS wriec | taverns | MC | paws | dramas STIWLAG SIDIAUTS ONY LNAWLV SUL