Health Insurance Claim Proof of Loss Form
1. Policyholder Information
Policy Number
Name of Insured
Date of Birth
Contact Number
Address
2. Patient Information (if different from Policyholder)
Patient Name
Relationship to Policyholder
Date of Birth
3. Claim Details
Date of Loss/Illness/Injury
Nature of Illness/Injury
Description of Incident
Diagnosis / ICD Code
4. Treatment & Provider Information
Name of Hospital/Provider
Date(s) of Treatment
Treatment/Services Rendered
5. Other Insurance Information
Is there any other insurance applying to this loss?
Yes
No
If yes, provide details
6. Claimant Declaration
Name
Signature
Date