CLAIMS NOTIFICATION - MEDICAL - SAGITARIES INSURANCE SERVICES

Submit your medical claim information online

At SAGITARIES INSURANCE / FPG, we’ve made it very easy for you to submit your medical claim online. Simply complete the following form and attach the relevant documents. We will then review your claim and if needed, a medical claim representative will contact you directly to confirm your claim details and request any additional information.

Basic Documents for Medical Insurance Claim

Download: Sagitaries Attending Physician's Result Form (to be filled and signed by attending physician)
Hospital statement of account with charge slips
Original Official Receipts of Hospital bill and Professional fees
Original Official Receipts of medicines purchased outside the hospital and their prescriptions (taken during confinement)
Admitting History Report
Discharge Summary

Need help with your claim? Call 0915-265-1203 / 0915-496-7047 or you can e-mail sagitariesinsuranceservices@gmail.com

PARTICULARS OF CLAIMANT

POLICY NUMBER*

PATIENT'S NAME*

ADDRESS*

INSURED'S NAME IF PATIENT IS A DEPENDENT

CERTIFICATE NO.

IF GROUP INSURANCE,NAME OF POLICY HOLDER

STATEMENT BY CLAIMANT(BY PARENT WHEN CLAIMANT IS A MINOR)

DATE & TIME ADMITTED

DATE & TIME DISCHARGED

IF AS A RESULT OF AN ACCIDENT, WHEN DID ACCIDENT OCCUR?(DD-MM-YY HH:MM)

GIVE A BRIEF DESCRIPTION OF CIRCUMTANCES

WAS THIS ACCIDENT REPORTED TO THE POLICE? IF SO, GIVE DETAILS

UPLOAD POLICE REPORT

WAS ANOTHER PARTY RESPONSIBLE FOR THE INJURY TO YOURSELF?*

IF SO, GIVE PARTICULARS

ARE YOU COVERED FOR THE WHOLE OR ANY OF THE ABOVE EXPENSES BY ?ANY SOCIAL SECURITY SYSTEM?(SSS)

ANY OTHER MEDICAL OR ACCIDENTAL INSURANCE?

ANY OTHER MEDICAL BENEFITS SCHEME?

IF "YES" TO ANY OF THE ABOVE, PLEASE STATE FULL PARTICULARS

UPLOAD DOCUMENTS

ATTENDING PHYSICIAN 'S RESULT FORM

HOSPITAL STATEMENT OF ACCOUNT WITH CHARGE SLIPS

ORIGINAL OFFICIAL RECEIPTS OF HOSPITAL BILL AND PROFESSIONAL FEES

ORIGINAL OFFICIAL RECEIPTS  OF MEDICINES PURCHASED OUTSIDE THE HOSPITAL AND THEIR PRESCRIPTIONS(TAKEN DURING CONFINEMENT)

ADMITTING HISTORY REPORT

DISCHARGE SUMMARY

DECLARATION

I HEREBY AUTHORIZE THE UNDERSIGNED PHYSICIAN AND/OR HOSPITAL ADMINISTRATOR TO RELEASE ANY INFORMATION ACQUIRED IN THE COURSE OF MY EXAMINATION OR TREATMENT

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I, THE UNDERSIGNED, DECLARE THAT THE PARTICULARS STATED ON THIS FORM ARE TRUE IN EVERY RESPECT. I HAVE SUPPLIED FULL INFORMATION ON ALL PARTICULARS RELEVANT TO THIS CLAIM, AND THE AMOUNTS CLAIMED HEREIN ARE LAWFULLY DUE TO ME UNDER TERMS, CONDITIONS, AND EXCEPTIONS OF THE ABOVE NUMBERED POLICY.