MEDICAL ASSISTANCE FORM

  

PERSONAL INFORMATION
Name: *
Sex: Male  Female
Date of Birth:
Nationality:
Travel Dates : to
Passport No. :
Policy No. :
File No. :
Coverage Amount :
Hospital / Hotel / Residence / Office Address :
City:
Country:
Zip Code: *
Telephone No : *
Fax :
Mobile :
E-Mail:

TOUR DETAILS

Tour Operator Name :
Telephone No :
Fax :

HOSPITAL DETAILS

HOSPITAL Name :
Room No :
Telephone No. :
Fax :
Treating Doctor's Name :
Clinic Telephone Number :
Clinic FAX Number :
Residence Telephone Number :
Mobile Number :
Comments:
 
Details of Medical Information Provisional Diagnosis
MEDICAL ASSISTANCE SERVICES REQUIRED
Ground Handling Services
Out Patient Medical Consult. Guarantee
Hotel Medical Visit Guarantee
Medical and Hospitalisation Guarantee
Road Ambulance Transfer Services
With Medical Escort  Without Medical Escort
Transport of Mortal Remains
Cash 
Assistance Cost Containment Services in Hospital
Cost of Medicine Delivery Services
Translator Services in Hospital
Undertaker Services & Assistance
Detection of fraudulent Medical Claims
Request for quotation of the above? Yes No

COMPANY DETAILS

Corporate / Family Member / Insurance / Assistance Company Name :
Telephone No :
Fax :
Mobile :
E-Mail:
Name of Sender :
Date :
  Please Note : Your are requested to FAX your assistance request to ARMS (INDIA)
FAX : +91-33-22291329 / 24743344