CLAIM
Claim
Type of Claim :
Accidental
Life
Claim Amount
*
:
Claim By
Name
*
:
Mobile
*
:
Patient
*
:
Rider
Captain
Passenger
Trip Information
Trip ID
*
:
Rider/Captain Name
*
:
Rider/Captain Mobile
*
:
Start Location
*
:
End Location
*
:
Incident Location
*
:
Incident Date & Time
*
:
Incident Details
*
:
Patient's Information
Name
*
:
Mobile
*
:
NID/Passport/Driving License
*
:
Gender
*
:
Male
Female
Payment Information
Select Payment Type :
Bank
Mobile Wallet
Account holder's name
*
:
Account Number
*
:
Bank Name
*
:
Branch Name
*
:
Bank Routing Number(if available):
Account Number
*
:
Account Type
*
:
bKash
Ucash
Rocket
SureCash
Nagad
Medical Document Upload
Doctor Advice
*
:
Discharge Certificate
*
:
Hospital Bill
*
:
Other Documents 1
*
:
Other Documents 2 :
Other Documents 3 :
Other Documents 4 :
Other Documents 5 :
Information of Deceased
Name
*
:
Mobile
*
:
NID
*
:
Gender
*
:
Male
Female
NID Copy :
Nominee Information
Nominee Name
*
:
Relationship with deceased
*
:
Spouse
Child
Father
Mother
Father-in-law
Mother-in-law
Nominee NID
*
:
Mobile
*
:
Bank Account Title
*
:
Bank Account Number
*
:
Bank Name
*
:
Bank Branch
*
:
Death Information
Place of death
*
:
Date of death
*
:
Reason of death
*
:
Duration of disease
*
:
Age at death
*
:
Died under Treatment:
Yes
No
Doctors Name
*
:
Contact Number
*
:
Address
*
:
Died at Hospital:
Yes
No
Hospital Name
*
:
Hospital Address
*
:
Hospital Number
*
:
Discharge Certificate
*
:
Death certificate
*
:
For identification or verification (detail of two local respected person)
Person 1
Name
*
:
Address
*
:
Mobile
*
:
Relation
*
:
Person 2
Name
*
:
Address
*
:
Mobile
*
:
Relation
*
:
I hereby declare to the best of my knowledge and belief that the information given are correct.
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