English-Khmer - Forte Insurance
English-Khmer - Forte Insurance
English-Khmer - Forte Insurance
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<strong>Forte</strong> <strong>Insurance</strong> (Cambodia) Plc. Siem Reap Branch<br />
325 Mao Tse Toung Boulevard, P.O. Box 565, Phnom Penh Mondul Stat Chas, Phum Salakanseng, Siem Reap<br />
Tel: (+855) 023 885 077 / 066 Fax: (+855) 023 986 922 Tel: (855) 63 963 355 Fax: (855) 63 963 610<br />
www.forteinsurance.com, info@forteinsurance.com<br />
srp@forteinsurance.com<br />
GROUP HOSPITAL & SURGICAL CLAIM FORM<br />
The Claimant must fully and accurately complete all the relevant areas in the part 1 of this form and must also attach original medical documents and original itemised hospital<br />
invoices which are claimed on the Policy. The documentation must be submitted to our company within thirty (30) days from the date of discharge from hospital. Any delay in<br />
settlement of the claim caused by non-compliance with the aforesaid requirements may result in interest charged by the hospital, and the interest will be borne by the<br />
employer/claimant. GñkTamTarsMNgRtUvbMeBjRKb;cMNucEdlBak;B½n§enAkñúgEpñkTI1 énsMNMuEbbbTenHeGay)aneBjelj nigc,as;las; RBmTaMgP¢ab;CamYynUvral;ÉksareBTü nigvik½ybR½tlMGitrbs;mnÞIreBTüEdlTak;Tg<br />
nwgkarTamTarsMNgenHmkeGayRkumh‘uneyIg´kñúgkMLúgeBl 30éf Kitcab;BIéfecjBImnÞIreBTü. karyWty:avkñúgkaredaHRsaysMNgEdlbNþalmkBIIkarminGnuvtþtamRbkarxagelIGacbNþaleGaymankarKitkarR)ak;BIsMNak;<br />
mnIÞreBTü ehIykarR)ak;enaHnwgRtUvCabnÞúkrbs;nieyaCkénGñkTamTarsMNg b¤GñkTamTarsMNg .<br />
A. CLAIMANT’S INFORMATION B½t’manGñkTamTarsMNg<br />
Name of Policyholder/Employer eQμaHm©as;b½NÑFanar:ab;rg¼nieyaCk:<br />
PART 1 EpñkTI1<br />
Policy No. elxb½NÑFanar:ab;rg: Plan CMerIskñúgb½NÑFanar:ab;rg: Claim No. elxTamTarsMNg: Patient’s Tel. elxTUrs½BÞTMnak;TMngGñkCMgW:<br />
Name of Patient: ………………………………….……. , Sex: M / F , Age: ………... , Employee or Dependant of Employee (Spouse / Child )<br />
eQμaHGñkCMgW ePT: Rbus ¼RsI Gayu nieyaCit / bnÞúkrbs;nieyaCit ¬bIþ ¼RbBn§ /kUn ¦<br />
B. SICKNESS CMgW<br />
Diagnosis eraKvinic½äy: ..……….…………………………………………………………….……… ; Has the illness been treated previously Yes / No If yes, please<br />
provide the date, name and address of the physician. etICMgWenHFøab;)anTTYlkarBüa)alBImunmkeT Føab; ¼minFøab; RbsinebIFøab; sUmpþl;kalbriecäT eQμaH nigGasydæanrbs;evC¢bNiÐt<br />
Date kalbriecäT: ………………….., Name eQμaH: ……………………………….., Address Gasydæan: .................................................................................................<br />
Is the illness due to pregnancy, abortion, miscarriage, sterilization, sub-fertility and infertility Yes / No ; If yes, please specify the condition and<br />
approximate date of commencement. etICMgWenHbNþalmkBIkarmanKP’ rMlUt rlUt eRkov b¤PaBGarEmneT Emn ¼minEmn RbsinebIEmn sUmbBa¢ak;BIsPaBCMgW nigkalbricäTcab;epIþm<br />
Condition sPaBCMgW: ………………………………………………………………………………………….…………………………………………, Date kalbriecäT: ………………………….<br />
C. INJURY karrgrbYs<br />
Diagnosis eraKvinic½äy: ...…..……….……………………………………….………………..………………… ; Date of Accident kalbriecäTeRKaHfñak;: …………………….,<br />
Time of Accident em:ageRKaHfñak; ...... : ...... am/pm ; Please describe where and how the accident happened. sUmerobrab;BITIkEnøgnigmUlehtuEdlnaMeGaymaneRKaHfñak;<br />
……………………..…………………………………...………………………………………………………………………………………………….……………………....<br />
……………………………………………………………………………………………………………………………………………………………………………………..<br />
D. OTHER INFORMATION B½t’manepSg²eTot<br />
Is the claimant entitled to make a claim from the National Social Security Fund (NSSF), or other insurance companies other than <strong>Forte</strong> <strong>Insurance</strong><br />
(Cambodia) Plc. Yes / No ; If yes, please provide the name of that insurance company. etIGñkTamTarsMNgmankarBak;Bn½§dl;karTamTarsMNgBIebLaCatirbbsniþsuxsgÁm<br />
¬b>s>s¦ b¤Rkumhu‘nFanar:ab;rgNaepSgeToteRkABIRkumhu‘nFanar:ab;rg <strong>Forte</strong> b¤eT man ¼Kμan RbsinebIman sUmpþl;eQμaHRkumhu‘nenaH …………………………………………………<br />
Name of Hospital/Clinic eQμaHmnIÞreBTü¼KIønik: ………………………………………………, Address Gasydæan: .……………………..……………………….…….……….<br />
Date the illness began: .…...….…………, Admission Date: ….…...…..………, Date of Surgery (If any) ….…...……………, Discharge Date: ….…...….…….…<br />
kalbriecäTcab;epIþmQW kalbriecäTcUlsMrakeBTü kalbriecäTeFIVkarvHkat; ¬ebIman¦ kalbriecäTecjBIeBTü<br />
Name of Attending Physician/Surgeon eQμaHevC¢bNiÐtBüa)al b¤evC¢bNiÐtvHkat;pÞal;: ….......…………………………..……., Tel No. elxTUrs½BÞ: …..…………………..………<br />
Payment by cheque shall be issued to sMNgCamUlb,Tanb½RtKYEtTUTat;CUn:<br />
<strong>Forte</strong>’s Hospital/Clinic Panel(s) mnIÞreBTü¼KIønikédKUrbs; <strong>Forte</strong> US$ .……...………; Employer nieyaCk US$ .…….………; Employee nieyaCit US$ .…….………;<br />
Authorized Person GñkTTYlsiTi§CMnYs US$ …...………… (Please provide a letter of authorization with this authorized person’s name as spelled in his/her National ID card<br />
or Passport. sUmpþl;lixitepÞrsiTi§edaysresreQμaHGñkTTYlsiTi§CMnYseGay)anRtwmRtUvtamGtþsBaØaNb½NÑ b¤lixitqøgEdnrbs;Kat;)<br />
MEDICAL INFORMATION AUTHORITY karpþl;siTi§cMeBaHBt’manxagevC¢sa®sþ<br />
I hereby authorize any hospital surgeon, medical practitioner or clinic that has attended to me or examined me for any reason to disclose all information with respect to the illness<br />
or injury, and to provide <strong>Forte</strong> <strong>Insurance</strong> (Cambodia) Plc with copies of all hospital or medical records, including any prior medical history. A copy of this authorization is<br />
considered to be as effective and valid as the original. ´sUmpþl;siTi§CUnevC¢bNiÐtvHkat; evC¢bNiÐtBüa)al KIønik b¤mnIÞreBTüEdl)anBüa)al b¤Binitüral;bBaðarbs;´kñúgkarbgðajnUvral;Bt’manEdlTak;TgnwgCMgW<br />
b¤karrgrbYs RBmCamYybNþac,ab;cMlgénkMNt;ehtueBTü b¤evC¢sa®sþ nigRbvtiþénCMgW CUnRkumhu‘n <strong>Forte</strong> <strong>Insurance</strong> (Cambodia) Plc.. ral;c,ab;cmøgénÉksarEdl)anRbKl;siT§ienH RtUv)ancat;TukfamanRbsiTi§PaB<br />
nigGacykCakar)andUcc,ab;edImEdr.<br />
_________________________________________________________________<br />
___________________________________<br />
Employer’s Signature and Company/Organization Stamp; Date: …………………….<br />
Claimant’s/Employee’s Signature; Date: ………………….…....<br />
htßelxanieyaCk nigRtarbs;Rkumhu‘n¼GgÁkar kalbriecäT htßelxarbs;GñkTamTarsMNg¼nieyaCit kalbriecäT Page 1
PART 2 – CERTIFICATION OF HOSPITALIZATION EpñkTI2 - viBaØabnb½RteBTü<br />
A. PATIENT’S INFORMATION B½t’manGñkCMgW<br />
Name of Patient: …………………………..……………………..., Sex: M / F , Age:………, Patient’s Contact Phone No.: …….……………………………….<br />
eQμaHGñkCMgW ePT :Rbus ¼RsI Gayu elxTUrs½BÞTMnak;TMngrbs;GñkCMgW<br />
B. DIAGNOSIS AND RELATED INFORMATION eraKvinic½äy nigB½t’manEdlBak;B½n§<br />
Was the patient an In-Patient etIGñkCMgWTTYlkarBüa)aledaysMrakeBTü or Out-Patient b¤minsMrakeBTü In-Patient sMrakeBTü or Out-Patient minsMrakeBTü <br />
Diagnosis / Extent of Injury eraKvinicä½y ¼ TMhMénrbYs: …………………………………………………………………….……………..……………………….………………<br />
1. The above mentioned condition is due to sPaBxagelIenHbNþalmkBI:<br />
i) Congenital Anomaly PaBxUcRTg;RTay b¤PaBxusRbRktIBIkMeNIt <br />
ii) Mental Disorder vibtiþpøÚvcitþ b¤srésRbsaT<br />
<br />
iii) Treatment of Teeth or Gum Tissue karBüa)aleFμj b¤sm
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